Willingness of urban formal sector workers to support a community-based health insurance scheme in Ethiopia

Abstract

Abstract Introduction The Ethiopian health system is primarily financed through household out-of-pocket expenditure and financial support from donors. High user fees lead to catastrophic health spending and limited use of services. To promote healthcare-seeking behavior and provide financial protection through enhanced domestic financing, the Ethiopian government has designed two types of health insurance schemes. These are a Community-Based Health Insurance (CBHI) scheme for the informal sector and the yet to be implemented Social Health Insurance (SHI) scheme for the formal sector. In the short run, these schemes are expected to function independently. However, in the long run it is anticipated that they will be combined, thereby pooling risk. Combining the two schemes requires solidarity across the two groups targeted by each of the schemes. Since it is likely that formal sector employees may have to bear the cost of subsidizing the CBHI scheme, this study aims to assess the extent to which formal sector employees are willing to support the CBHI scheme. Methods The paper is based on a survey of 1,919 formal sector employees and pensioners residing in the major administrative regions of the country. A survey experiment was used to elicit support for the CBHI scheme. Respondents were randomly allocated to one of five cases. These cases differed in terms of the information provided regarding the source of the CBHI subsidy and the benefits associated with the CBHI. Support for CBHI was assessed using descriptive statistics, binary and ordered logit models. Results There is strong support from urban formal sector employees for the CBHI scheme. Regardless of the scenario presented, and despite some regional variation, the key result is that at least 66% of the surveyed participants, adjusting for non-response, supported the CBHI scheme. Good knowledge of insurance increased support while existing access to health insurance lowered it. Conclusion The study provides strong evidence of solidarity and the willingness of formal sector employees to support the CBHI scheme. While this bodes well for the sustained expansion of the CBHI, it is ironic, as formal sector employees are resisting the introduction of the SHI. This reluctance stems from concerns about the costs and skepticism of the benefits of the proposed SHI, whereas the positive outcomes associated with the CBHI are widely known.