Quantitative results
Socio-demographic characteristics
Of the 337 total study participants, 324 (96%) took part in this study, 79% urban and 21% rural. All respondents fell between 18 and 62 years of age, with a mean age of 28.12 years (Table 1).
Table 1፡ Socio-demographic and socio-economic characteristics of employees in Takusa Woreda, 2015 (n=324)
Variables
|
Category
|
Frequency (n)
|
Percentage (%)
|
Age
|
18-22
|
32
|
9.9
|
|
23-27
|
164
|
50.6
|
|
28-32
|
80
|
24.7
|
33-37
|
16
|
4.9
|
|
>37
|
32
|
9.9
|
Sex
|
Male
|
182
|
56.2
|
|
Female
|
142
|
43.8
|
Marital status
|
Single
|
154
|
47.5
|
|
Married
|
152
|
46.9
|
|
Others+
|
18
|
5.6
|
Educational status
|
Primary School
|
12
|
3.7
|
|
Secondary School
|
25
|
7.7
|
|
Diploma
|
161
|
49.7
|
|
Degree
|
126
|
38.9
|
Working experiences in years
|
0.5-2
|
90
|
27.8
|
|
2.1-4
|
81
|
25.0
|
|
5-7
|
57
|
17.6
|
|
8-10
|
52
|
16.0
|
|
>10
|
44
|
13.6
|
Size of household
|
1-2
|
151
|
46.6
|
|
3-4
|
107
|
33.0
|
|
5-6
|
44
|
13.6
|
|
>6
|
22
|
6.8
|
Number of dependent children
|
No
|
200
|
61.7
|
|
1-2
|
103
|
31.8
|
|
>2
|
21
|
6.5
|
Number of dependent nuclear children
|
No
|
240
|
74.1
|
|
1-2
|
59
|
18.2
|
|
1-2
|
59
|
18.2
|
|
>2
|
25
|
7.7
|
Working pool
|
ADP
|
15
|
4.6
|
|
AGP
|
22
|
6.8
|
|
CP
|
22
|
6.8
|
|
CSP
|
231
|
71.3
|
|
OP
|
34
|
10.5
|
NB: + =Widowed, divorced; ®= Muslim, Protestant; © =Tigre, Oromo; ADP: Administration pool; AGP: Agricultural pool; CP: Communication pool; OP: others pool; CSP: Civil service pool
Employees’ Monthly net income
Nearly one third, 29 percent, of the research units had 1500-1999 Ethiopian Birr net monthly revenue (ETB). With a minimum of 500 and a limit of 20,000ETB, the average monthly net employee income was 2,477.17 (Figure 1).
Health and health related characteristics
Most, 77.5%, workers were able to get a health center, 43.2% were able to get a private clinic, 37% were able to get to the hospital, and 21.6% were able to get a pharmacy nearest health post. Generally speaking, 96% of them were available for health insurance, while just 4% were not.
More than half, 54.9% of study units or their families have been ill for the last 12 months, and the remainder has been well. Out of 180 family sick stories, 44.1% had been ill for less than 3 days, 26.3% had been ill for 1 week, and 19% had been ill for more than 3 weeks. Among the sick respondents, 53.3% had to get outpatient health care from the health department, 21.4% had to get help from the private clinic, and 20.5% from the doctor.
In sick respondents, 49.2% had paid less than 83 ETB, and 22.3% had paid more than 360ETB. Overall, the total amount charged for outpatient sickness in the last 12 months was 548.41, ranging from 0 (maybe workers, exempted facilities, etc.) to 11,000. In all the sick 180 participants, only 24.4% were admitted.
Nearly three-fourths, 71.6 %, reimbursement of medical bills was out of pocket, and others, 73.1% of the state that they were unable to meet all their manufacturing expenses on their own. Furthermore, 67.6% of workers were unhappy with the consistency of health care delivery (Table 3).
Table 3፡ Medical cost payment system and satisfaction of employees in Takusa Woreda, 2015(n=324)
Questions
|
Category
|
Frequency
|
Percentage
|
Who paid your current medical cost
|
Self
|
232
|
71.6
|
Government
|
51
|
15.7
|
Both
|
35
|
10.8
|
Others*
|
6
|
1.9
|
Who should cover HS Cost? (n=453)
|
Customers
|
207
|
45.7
|
Government
|
203
|
44.8
|
Both
|
53
|
11.7
|
Can government fund cover all health service
|
No
|
246
|
75.9
|
Yes
|
79
|
24.1
|
Out-of-pocket payment cover all output costs
|
No
|
237
|
73.1
|
Yes
|
87
|
26.9
|
Satisfaction by health service payment system
|
No
|
216
|
66.7
|
Yes
|
108
|
33.3
|
Satisfaction by quality of health service
|
No
|
219
|
67.6
|
|
Yes
|
105
|
32.4
|
How SHI membership shall be (n=215)
|
Voluntary
|
198
|
92.1
|
Mandatory
|
17
|
7.9
|
* = Family, employer
Awareness and attitude characteristics
Among all, 66.7% of study units replied as they understood what SHI was, but just about a third, 34% of employees were well aware of SHI. The bulk of workers, 70.1%, had a favorable attitude, while 29.9% had an unfavorable attitude towards the SHI system (Table 4).
Table 4፡ Attitude of governmental employees for SHI in Takusa woreda, 2015 (n=324)
Variables
|
Category
|
Frequency
|
Percentage
|
I’m healthy enough that I really don’t need SHI
|
Yes
|
227
|
70.1
|
No
|
97
|
29.9
|
I think SHI is not worth the money it cost
|
Yes
|
131
|
40.4
|
No
|
193
|
59.6
|
I’m more likely to take risks than the average person
|
Yes
|
250
|
77.2
|
No
|
74
|
22.8
|
I can overcome illness without help from a medically trained person
|
Yes
|
278
|
85.8
|
No
|
46
|
14.2
|
SHI would not solve the premium of health service expense
|
Yes
|
249
|
76.85
|
No
|
75
|
23.15
|
Attitude
|
Unfavorable
|
97
|
29.90
|
Favorable
|
227
|
70.10
|
Source of information
The awareness-building exercise, accompanied by TV, was the primary source of knowledge for SHI (fig 2).
Demand of Social Health Insurance
The 61.1% of respondents had strong demand, equivalent to two-thirds, while the remaining 38.9% had poor demanded (Figure 3). The mean monthly payment was 2.23 out of 208 research units that able to pay, varying from 0.01% to 8%. 34.9% were afraid of low-quality health care provision, 27.4% were due to insecurity, among those who were not able to participate and pay for SHI membership. The remaining 16.4% denied should get free health care because of health workers it may be influenced by corruption; payment of imbalance and service received a lack of understanding.
Factors for Demand of SHI
In the binary logistic regression model, nine variables were eligible to be interred into multiple logistic regression (p<0.2). But in the multiple regression model, only three variables which are rural residence (p=0.039), family size (p=0.04), and cost of outpatient treatment during illness in the last 12 months preceding the data collection period (p=0.006), were found to be associated with demand of SHI among employees (p<0.05).
Employees who had 5-6 family sizes were 5.5 times more likely to had a demand for SHI as compared to those who had 1-2 family size (AOR=5.50, 95%CI=1.01-30.08). It was also found that for rural residents, the likelihood of SHI demand was 3.3 times higher than for urban residents (AOR= 3.29, 95 percent CI= 1.06-10.20). In comparison, workers who charged more than 360 ETB for outpatient care during sickness in the last 12 months were 5.2 times more likely than those who paid less than 83ETB (AOR= 5.22, 95% CI= 1.61-16.95) to have a demand for SHI compared to those who paid less than 83ETB (Table 5).
Table 5፡Associated factors for demand of SHI among employees in Takusa Woreda, 2015 (n=324)
Variables
|
Category
|
SHI Demand
|
COR (95%CI)
|
AOR (95%CI)
|
|
|
Poor
|
Good
|
|
|
Attitude
|
Unfavorable
|
26
|
18
|
1
|
|
Favorable
|
100
|
180
|
2.6(1.36-4.97)
|
2.90(0.80-10.52)
|
Family size
|
1-2
|
66
|
85
|
1
|
1
|
3-4
|
42
|
65
|
1.20(0.73-1.99)
|
1.33(0.40-4.38)
|
5-6
|
10
|
34
|
2.64(1.22-5.73)
|
5.50(1.01-30.08)*
|
> 6
|
8
|
14
|
1.36(0.54-3.43)
|
5.41(0.51-57.04)
|
Residence
|
Urban
|
107
|
149
|
1
|
1
|
Rural
|
19
|
49
|
1.85(1.03-3.32)
|
3.29(1.06-10.20) *
|
Marital status
|
Single
|
69
|
85
|
1
|
1
|
Married
|
51
|
101
|
1.61(1.01-2.55)
|
1.86(0.63-5.23)
|
Others
|
6
|
12
|
1.62(0.58-4.55)
|
1.71(0.15-19.69)
|
Others
|
9
|
5
|
1
|
1
|
Dependent children
|
0
|
86
|
114
|
1
|
1
|
1-2
|
37
|
66
|
1.35(0.82-2.20)
|
0.61(0.22-1.69)
|
>2
|
3
|
18
|
4.53(1.29-15-86)
|
|
Nuclear children
|
0
|
105
|
135
|
1
|
1
|
1-2
|
15
|
44
|
2.28(1.20-4.32)
|
2.46(0.86-7.04)7
|
> 2
|
6
|
19
|
2.46(0.95-6.39)
|
0.69(0.167-2.82)
|
Cost of Treatment
|
<83
|
31
|
57
|
1
|
1
|
83-130
|
9
|
12
|
0.73(0.28-1.91)
|
0.47(0.14-1.58)
|
131-215
|
5
|
13
|
1.41(0.46-4.34)
|
1.66(0.46-6.07)
|
216-360
|
5
|
7
|
0.76(0.22-2.6)
|
1.19(0.30-4.77)
|
>360
|
5
|
35
|
3.81(1.35-10.71)
|
5.22(1.61-16.95)*
|
Health status
|
Healthy
|
71
|
75
|
1
|
1
|
Sick
|
55
|
123
|
2.12(1.34-3.34)
|
2.90(0.80—10.52)
|
*=Those variables which had significances association (p<0.05)
Qualitative findings
Awareness related characteristics
Twelve workers, six men, and six women were interested in 2 FGDs in total. Of these, 8 were professional health professionals. Nearly all FGD respondents were well educated about SHI. SHI was described by the head of the Delgi Health Center as "Like rich people purchasing a car and insuring it, SHI was a way for members to pay based on their income to become a member." A district hospital manager stated the condition as “…All paid members may not get health services by chance, but like other organizations such as ‘Eddire’ by understanding this it was an opportunity in which one would help others.”
Health institution that would provide SHI service
In the thematic analysis, half of the respondents agreed as any accredited health institution which was voluntary to provide the service would be delegated. The head of Delgi health center said that “… Gambi Hospital can give the service in collaboration with Felegehiwot referral Hospital. Since as they are qualified and present inside Ethiopia…” On the other hand, a 25 years old female stated that “… start the service by governmental health institutions followed by private institutions based on the standards. If any institutions did not fulfill the standard it would be better to upgrade it through time …”
Contrarily, half of them respond as only governmental health institutions, excluding health post would provide the service. A small enterprise officer complains as “private health institutions were profit finders, they might need to collect over income… if one person was ill and goes there, the customer would pay 70-100 birr for a card only. If it was for Laboratory, drugs, and other services, we can estimate how much he would pay.”
Preparedness of health institutions
Regarding the preparedness of health institutions, the majority of FGD study groups replied as almost all of them were as it was. Health institutions that would take contract agreement were not selected; lack of additional manpower, classrooms, supplies; lack of discussion forum and promotion; lack of infrastructure; unpreparedness of membership files were some of the indicators. A Nurse employee said that “… in our woreda among five health centers, 2 of them hadn’t, even once, the medical laboratory professional.” A 25 year’s old employee responds as “...Still, those health institutions which will provide the service are not identified. It indicates as there was no preparedness. The manpower, classes, and other inputs are as previous.” A 32 years old nurse said that “employers hadn’t any idea about SHI…they didn’t know how much percent they would pay for their employee, how would pay it…”
Scope of SHI program
Thematic analysis showed that the scope of SHI services would be all health services, except beauty, at any time and place up to abroad referral system including both medical & non-medical related costs. A Small enterprise officer, 42 years old, said that “…SHI must provide all health services at any time and any place, except those done for beauty. There must be a referral system from Woreda up to specialized Federal Hospitals, even outside of the country. Unless it incorporates complicated services why it needs to be a member of SHI because he can get simple health services by himself…” Majority of them also agreed as all employee’s would-be member of SHI.
A 28 years old district hospital manager said that “…when I see mine, it would be 117.33ETB per month. I should save it… since I am health professionals, had better awareness about the disease, and I can care for myself from the disease.” He also stated his fear as “…If members paid consecutively and unfortunately, they did not get health service by SHIA due to being healthy, they might think paying without benefit…”. They also mentioned that members might be enforced by health professionals to give referral papers for them whether the case was beyond the scope of contracted health institutions or not.
Strength and weakness of SHI scheme
According to Delgi health center head, SHI had holistic profits. He stated it as “…when health institutions were strengthened, supplies would be accessible and then accessible quality service would be given to members. It also reduces those ill persons that stayed at home due to shortage of money…” A 32 years old environmental health officer expressed the strength of SHI as “… civil servants' health-seeking behaviors would be increased. When they were felt ill, they would come to get treatment. SHI was used as retires. In the retires program, some percent of the money was collected throughout their active working time and it would be used at the time of passive employment. SHI was just like this; the income was collected during the healthy time and used when they were ill”. The majority of them agreed as the SHI program provides both prevention and treatment services. They state it as, when members feel simply ill, they would come and got health service, pieces of advice about health education, because they had no financial problems. So, this can be considered as preventive as well as curative. On the other hand, participants respond as SHI had its weakness. A 25 female raised the issue in that “… membership payment, and its benefit was not balanced. Even after paying this amount of money, complicated health services were not provided…”
Table 6: Strength and weakness of SHI in Takusa Woreda, 2015
Strength
|
Weakness
|
Provide both Preventive and treatment
|
3% payment too high
|
Health seeking behavior increases
|
Restriction of health services
|
Accessing quality health services
|
Imbalance membership payment between SHI & CBHI with equal health service consumption
|
Give universal health services
|
Non refunded collected money
|
Strength finance of health institutions
|
Imbalanced membership payment & benefit
|
Reduce out of pocket payment
|
Being member of SHI by mandatory
|
Sustainability of SHI program
A thematic content analysis revealed that to increase uptake of SHI and to sustain it, inputs should be fulfilled timely. A male Nurse who was 30 years old stated as “… to sustain SHI program, pharmaceutical fund supply agency should have fast dispatching system of inputs to health institutions...” Also, a 25 year’s old female said that “…the idea should not be declared from administrative bodies only and forwarded to members. Rather, it was better to discuss with employees and customize with our country context…” She also said that “….as membership monthly payment was too much it was better to create a discussion forum and then after arriving on consensus to increase by starting from smallest monthly payment system…”
This study revealed that the following indicators were enabling factors for good demand of SHI in the future.
- Use networked finance system
- Conduct discussion forum
- Maintain quality of health service
- Reduce payment
- Start CBHI as a role model
- Do HI preparedness assessment
- Auditing HI regularly
- Prevent corruption
- Monitor the program
- Avail inputs
- Promote SHI
- Voluntariness based SHI
- Assign responsible body
- Unify 3 type of HI