The results of this study indicate that 65% of the employees were willing to join the proposed SHIS. This is lower than study conducted in Nigeria, and Addis Ababa which was 83% and 90% respectively (12,13). But it is higher than a study done in south India where only 39% were willing to join (14). From this study, among those individuals who were willing to join SHIS only 27.8 % were willing to pay the proposed 3% of their monthly salary, the remaining 72.2% the respondent were willing to pay less than 3% of their monthly salary. This result is two times lower than the study conducted in Wolaita Sodo (Ethiopia) where 74.4% of the respondents willing to pay 3%. But it is greater than study conducted in Addis Ababa(Ethiopia) St. Paul’s hospital: only 17% health of workers were willing to pay 3% of their monthly salary. The difference could be due to less promotional efforts being taken by health insurance agency to the study area and also some employees may consider their health insurances should be covered by their employer’s (15, 16).
The average willingness to pay of the respondent for social health insurance is 56.40 ETB (US$ 2.08) per month which is 1.88% of their monthly. Their WTP per person per year reached 676.80 ETB (US$25.06). This is almost similar with study done in Addis Ababa which was about 57.94 ETB per month. And also lower than study conducted in Wolaita (Ethiopia) which was 81.66 ETB (US$ 3.02) per month. The rate of premium willingness to pay is greater than with another study conducted in Addis Ababa and Iran which revealed that 1.58% and 1.39% of their monthly salary respectively. And little bit lower than study conducted in Namibia which reported as 2% of their monthly salary per month. The disparity might be related to the difference in cost of living conditions and their perception of being at risk of illness (13, 16, 17, 18, & 19).
The other objective of this study was identifying the determinants of willingness to pay for health insurance. Respondents who had >4 family’s members were 94 % less likely WTP for SHIS than those with <4 family’s (AOR; 0.060, 95% CI (.023 -.157). This result indicates family size has a negative impact on employee’s willingness to pay. This might be because the higher the family size, the lesser per capita income and may prioritize other expenditure rather than health insurance that means a large family with lower income may affect their willingness to pay. This result is supported by the study done in Iran and Adama (Ethiopia) where people who had large family size did not want to pay (18, 20). But it is inconsistent with study conducted in Nigeria where family size has positive relation (21). This disparity might be due to beneficiary stated in the Ethiopian SHI proclamation 690/2010.
Marital status was another factor associated with WTP for SHIS of respondents. Those married respondents were 91.6 % less likely willing to pay as compared to unmarried (AOR;.084 95%CI.028-.254). Three explanations might be given for this result. First, married employees are less willing to pay due to high expenses they face related to their families over the ‘unmarried ’employees. Second, those respondents who were married and both of them were employees might not agree to contribute the premium at the same time even though the proclamation stated any employees should pay to the scheme. But unmarried ones contribute for the scheme is only he/she, therefore they will be more willing to pay than married ones. Third unmarried employees have more income disposable than married employees thus they are more willing to pay. In other words it shows effect of family income. This study is in line where study conducted in Wolaita(Ethiopia) but inconsistent with study conducted in India (16). Educational status is positively associated with employees willingness to pay; respondents who had first degree and above were 3.6 times more likely WTP for SHIS than those respondents who had diploma and below (AOR; 3.608, 95%CI 1.177–11.061). This means that more educated employee would be willing to contribute the premium. This finding is consistent with a study done in (Iran, Namibia, and Addis Ababa) where, those with higher level of education willing to pay for National Health Insurance Scheme (13, 18, 19,). This might be due to more educated employee were easily adopt new program and they can have an access and utilize information easily than less educated ones. And also those with high educational level & high monthly income might be a reason to prefer SHI because they can easily contribute.
An employee’s monthly salary positively associated with WTP for social health insurance scheme, respondents with salary of more than 3500ETB were 8 times more likely willing to pay for SHI than those with monthly salary was less than 1500ETB (AOR; 8.690, 95%CI 1.446–52.219). It implies that the high income the more willing to pay for the proposed premium. This agrees with a study done in china, Iran, India, Namibia, and Addis Ababa where respondents with higher income were more willing to pay for health insurance than those with lower income (7, 13,14 18, 19,and 22). This may be comparatively those with the higher income can have an ability to afford the premium easily and it promotes one of the principles of health insurance known as risk pooling. On the other hand respondents with less income may prioritize other expenditure rather than health insurance.
Employees and their families who experienced illness in the last twelve month were found another important factor for willingness to pay of the premiums of SHIS. Respondents whose family was experienced any type of illness in last 12 months before interview were 3 times more willing to pay than those who were not experienced any illness in the past one year (AOR; 3.024, 95% CI (1.067–8.571). This result is consistent that was found in Cameron, Efratana Gedem district and Adama (Ethiopia) (20, 23, 24). However, such kind of preference of social health insurance leads to an adverse selection which is one of the major challenges of health insurance. Because if there is imbalance of enrolment between sick and healthy members, frequent visit of health facility by chronic patient increases that leads to high claim for the scheme. And it could be challenge for financial sustainability of the social health insurance scheme. Employees who perceived good quality of health service at health facility were 3 times more willing to pay for the scheme compared to who did not perceived good quality of health service (AOR = 3.150, 95%CI:1.140–8.699). Similarly, study done in, Addis Ababa and kewet and Efratana Gedem district (Ethiopia) showed that quality of health service were one of the most significant factor for WTP for SHIS (9, 24). This indicates that improve the quality of health services might leads to increase the willingness to pay of an employees.
Availability of drugs was another factor associated with WTP for SHIS of respondents. Respondents who perceived the prescribed drugs were always available at health facility were 8 times more likely to willing to pay compared to who did not perceived always is available (AOR = 8.127, 95% CI:3.094–21.342). This result is in line with qualitative research on knowledge and preference of health insurance that was done in Addis Ababa where service availability (drugs, investigations, physicians) can affect the willingness to pay (9). This is in fact that one’s people insured they want to be secured for drug availability because they do not want to practice out of pocket expenditure for medical services. They already pre-paid for the service therefore they will not want to expose to extra expenditure (to buy drugs and other medical services).
Similarly respondents who thought the benefit packages is enough were 5 times more willing to pay than who perceived it is not as enough (AOR = 5.229, 95%CI:2.230–12.594). This is in line with study done in Addis Ababa where most focus group discussants agreed comprehensiveness of benefit packages found to be limited and affect their willingness to pay. And also the result is supported study conducted in Ghana where members of health insurance were satisfied with the benefit package and they were eager to renew their membership (9, 25).
Furthermore, employees who perceived the beneficiary of SHIS is enough were 3times more likely WTP for SHIS than respondents who perceived the proposed beneficiary of SHI is not enough (AOR = 3.264, 95%CI 1.303 - 8.179). Similarly a qualitative study done in Addis Ababa shows that the respondents dissatisfied with the current proposed beneficiary and that can be a cause for less willingness to pay for SHIS. And they perceived many dependents are in their families which are out of list of beneficiary in the proclamation of SHI. They may want to add extra families beyond the stated in the proclamation. Therefore respondents stated that proposed beneficiary of SHIS should be updated (9). Because extended family is common in Ethiopia and they consider ignored the type of strong social attachment between families and also they consider their family income. Where larger family members exclude out of the scheme, the family members may expose to financial shortage when they seek health care.
Limitation of the study
It included only monthly salary of the employee as monthly income. Another source of income of the respondents not assessed.