Willingness and perceived ability to pay for Uganda’s proposed national health insurance scheme among informal sector workers in Iganga and Mayuge districts, Uganda: A contingent valuation method

Abstract

High out-of-pocket expenditures (OOPE) continue to make access to healthcare a challenge among informal sector workers in most low-income countries. In response, Uganda has proposed a national health insurance scheme (NHIS), although the informal sector's willingness and ability to pay for it remains unexplored. This study assessed the willingness and perceived ability to pay for the proposed NHIS, along with their determinants, among informal sector workers in Iganga and Mayuge Districts, Uganda. A cross-sectional study was conducted in Iganga and Mayuge Districts between April and May 2019. A contingent valuation method using the bidding game technique was used to elicit the willingness to pay (WTP). A total of 853 informal sector workers were randomly selected and all interviewed (100% response rate). Seven focus group discussions (FGDs) were also conducted. Logistic regression analysis was done to identify the determinants of WTP for the proposed NHIS. Qualitative data were analyzed thematically. The majority 695/853, (81.5%) and 633/853, (74.2%) of the respondents were willing and believed that they would be able to pay for NHIS, respectively. The median WTP was UGX 25,000 (USD 6.8) annually. WTP was significantly associated with being a fisherfolk (AOR: 1.70 95%CI: 1.04-2.79, P = 0.035), being in the fourth wealth quintile (AOR: 2.98, 95% CI: 1.56-5.65), "not having heard" about health insurance (AOR: 0.50 95%CI: 0.23-0.86, P = 0.032), and "not having membership in a savings group" (AOR: 0.51, 95%CI: 0.34-0.76, P < 0.001). Most FGD participants reported willingness to pay for the proposed scheme; however, some doubted their ability to do so due to extreme poverty levels and unstable income. The WTP for the proposed NHIS in the informal sector was high. However, raising awareness and considerations for the indigent when setting appropriate premiums should be a priority.