Willingness to pay for Community Health Insurance among taxi drivers in Kampala City, Uganda: a contingent evaluation

Multidimensional determinants of willingness to pay for community-based health insurance in Ethiopia and its implication towards universal health coverage: A narrative synthesis

Pooling resources to pay for healthcare services and attain universal health coverage is a viable global agenda, especially for underdeveloped health systems. Ethiopia has implemented community-based health insurance (CBHI) since 2011 to improve healthcare funding. However, comprehensive evidence on the demand and determinants of health insurance in Ethiopia is lacking. Therefore, this review aimed at identifying determinants of willingness to pay (WTP) for CBHI in Ethiopia. A narrative review was conducted using search terms from PubMed, Science Direct, Scopus, African Journal Online, and Google Scholar databases. Screening process considered publication year, settings, English language, and study participants. Newcastle Ottawa tool assessed the quality of included studies. A thematic framework was applied. The review protocol was registered in PROSPERO with an ID number CRD42022296840. The review included 10 studies. The synthesis identified 25 determinants of WTP for CBHI in Ethiopia. Socio-demographic and economic, scheme-related, and health-related determinants of WTP for the CBHI were identified. Determinants of household WTP for CBHI in Ethiopia were multi-dimensional. Socio-demographic, socio-economic, scheme-related, and health-related factors are among the common determinants documented. CBHI is thus an alternative and potential source of financing for the healthcare system, primarily for people with low socioeconomic status and a fragile health system. The health system, socioeconomic leaders, and political figures play a significant role in influencing communities towards WTP for CBHI while increasing government spending on health toward UHC.

Health Financing Reforms in Uganda: Dispelling the Fears and Misconceptions Related to Introduction of a National Health Insurance Scheme Comment on "Health Coverage and Financial Protection in Uganda: A Political Economy Perspective"

Uganda introduced health financing reforms that entailed abolition of user fees, and in due process planned to introduce a National Health Insurance Scheme (NHIS). This paper accentuates a contextual and political-economic analysis that dispels the fears and misconceptions related to introduction of the insurance scheme. The Grindle and Thomas model is used to depict how various factors affect decision making by policy elites concerning a particular policy at a particular time. Drawing lessons from the sub-Sahara region and in particular, Ghana and Rwanda's experience, it is clear that the political will of the executive led by the president in many countries is a key determinant in bringing about health reforms. In this paper, we provide insights based on contextual and political-economic analysis to countries in similar setting that are interested in setting up NHISs.

Dropping out of voluntary community-based health insurance in rural Uganda: Evidence from a cross-sectional study in rural south-western Uganda

AIM

Community Based Health Insurance (CBHI) schemes have become central to health systems financing as avenues of achieving universal health coverage in developing countries. Yet, while emphasis in research and policy has mainly concentrated on enrolment, very little has been apportioned to high rates of dropping out after initial enrolment. The main aim of this study is to understand the factors behind CBHI dropping out through a cross-sectional quantitative research design to gain insights into curtailing the drop out of CBHI in Uganda.

METHODS

The survey for the quantitative research component took place between August 2015 and March 2016 covering 464 households with under-5 children in south-western Uganda. To understand the factors associated with dropping out of CBHI, we employ a multivariate logistic regression on a subsample of 251 households who were either currently enrolled or had enrolled at one time and later dropped out.

RESULTS

Overall, we find that 25.1 percent of the households that had ever enrolled in insurance reported dropping out. Household socioeconomic status (wealth) was one of the key factors that associated with dropping out. Larger household sizes and distance from the hospital were significantly associated with dropping out. More socially connected households were less likely to drop out revealing the influence of community social capital in keeping households insured.

CONCLUSION

The findings have implications for addressing equity and inclusion concerns in community-based health insurance programmes such as one in south-western Uganda. Even when community based informal system aim for inclusion of the poorest, they are not enough and often the poorest of the poor slip into the cracks and remain uninsured or drop out. Moreover, policy interventions toward curtailing high dropout rates should be considered to ensure financial sustainability of CBHI schemes.

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

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

Household preferences and willingness to pay for health insurance in Kampala City: a discrete choice experiment

INTRODUCTION

Uganda is in discussions to introduce a national health insurance scheme. However, there is a paucity of information on household preferences and willingness to pay for health insurance attributes that may guide the design of an acceptable health insurance scheme. Our study sought to assess household preferences and willingness to pay for health insurance in Kampala city using a discrete choice experiment.

METHODS

This study was conducted from 16th February 2020 to 10th April 2020 on 240 households in the Kawempe division of Kampala city stratified into slum and non-slum communities in order to get a representative sample of the area. We purposively selected the communities that represented slum and non-slum communities and thereafter applied systematic sampling in the selection of the households that participated in the study from each of the communities. Four household and policy-relevant attributes were used in the experimental design of the study. Each respondent attended to 9 binary choice sets of health insurance plans that included one fixed choice set. Data were analyzed using mixed logit models.

RESULTS

Households in both the non-slum and slum communities had a high preference for health insurance plans that included both private and public health care providers as compared to plans that included public health care providers only (non-slum coefficient β = 0.81, P < 0.05; slum β = 0.87, p < 0.05) and; health insurance plans that covered extended family members as compared to plans that had limitations on the number of family members allowed (non-slum β = 0.44, P < 0.05; slum β = 0.36, p < 0.05). Households in non-slum communities, in particular, had a high preference for health insurance plans that covered chronic illnesses and major surgeries to other plans (0.97 β, P < 0.05). Our findings suggest that location of the household influences willingness to pay with households from non-slum communities willing to pay more for the preferred attributes.

CONCLUSION

Potential health insurance schemes should consider including both private and public health care providers and allow more household members to be enrolled in both slum and non-slum communities. However, the inclusion of more HH members should be weighed against the possible depletion of resources and other attributes. Potential health insurance schemes should also prioritize coverage for chronic illnesses and major surgeries in non-slum communities, in particular, to make the scheme attractive and acceptable for these communities.

Health insurance awareness and its uptake in India: a systematic review protocol

INTRODUCTION

Health insurance is one of the important approaches that can help in boosting universal healthcare coverage through improved healthcare utilisation and financial protection. This objectives of this review are to identify various interventions implemented in India to promote awareness of health insurance, and to provide evidence for the effectiveness of such interventions on the awareness and uptake of health insurance by the resident Indian population.

METHODS AND ANALYSIS

A systematic review will be carried out based on the Cochrane handbook for systematic reviews of interventions. The review will include experimental and analytical observational studies that have included adult population (>18 years) in India. We will include any intervention, policy or programme that directly or indirectly affects awareness or uptake of health insurance. The following outcomes will be eligible to be included: awareness or health insurance literacy, attitude such as readiness to buy health insurance or decision making, uptake of health insurance, demand-side and supply-side factors for awareness of health insurance, and awareness as a factor for uptake and re-enrolment in health insurance. Databases such as MEDLINE (PubMed), Web of Science, Scopus, 3ie impact evaluation repository and Social Science Research Network will be searched from January 2010 to 15 July 2020. Additionally, important government websites and references of the included studies will be scanned to identify potential records. Three authors, independently, will carry out screening and data extraction. Studies will be categorised into quantitative and qualitative, and mixed-methods synthesis will be employed to analyse the findings.

ETHICS AND DISSEMINATION

This review will be based on published studies and will not recruit human participants directly, therefore, ethical clearance is not applicable. We will disseminate the final review findings in a national or international conference and publish in a peer-reviewed journal.

Willingness to pay for private health insurance among workers with mandatory social health insurance in Mongolia

Background

High out-of-pocket health expenditure is a common problem in developing countries. The employed population, rather than the general population, can be considered the main contributor to healthcare financing in many developing countries. We investigated the feasibility of a parallel private health insurance package for the working population in Ulaanbaatar as a means toward universal health coverage in Mongolia.

Methods

This cross-sectional study used a purposive sampling method to collect primary data from workers in public and primary sectors in Ulaanbaatar. Willingness to pay (WTP) was evaluated using a contingent valuation method and a double-bounded dichotomous choice elicitation questionnaire. A final sample of 1657 workers was analyzed. Perceptions of current social health insurance were evaluated. To analyze WTP, we performed a 2-part model and computed the full marginal effects using both intensive and extensive margins. Disparities in WTP stratified by industry and gender were analyzed.

Results

Only < 40% of the participants were satisfied with the current mandatory social health insurance in Mongolia. Low quality of service was a major source of dissatisfaction. The predicted WTP for the parallel private health insurance for men and women was Mongolian Tugrik (₮)16,369 (p < 0.001) and ₮16,661 (p < 0.001), respectively, accounting for approximately 2.4% of the median or 1.7% of the average salary in the country. The highest predicted WTP was found for workers from the education industry (₮22,675, SE = 3346). Income and past or current medical expenditures were significantly associated with WTP.

Conclusion

To reduce out-of-pocket health expenditure among the working population in Ulaanbaatar, Mongolia, supplementary parallel health insurance is feasible given the predicted WTP. However, given high variations among different industries and sectors, different incentives may be required for participation.

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.