Willingness to join and pay for Social Health Insurance  among Public Servants in Arba Minch town, Gammo Zone, Southern Ethiopia


 Background Ethiopia plans to introduce social health insurance scheme for the formal sector. The scheme contribution will be collected as 3% of an employee’s monthly gross salary from both employee and employer. The scheme is expected to enhance access to health care, however, there is a concern that majority of civil servants were not willing to join and pay for it. Therefore, this study aims to assess willingness to join and pay for the newly proposed social health insurance among public servants in Arba Minch town, Southern Ethiopia.Methods Institution based, Cross-sectional study design was used among 713 randomly selected public servants in Arba Minch town. Multi-stage stratified random sampling technique was used to select participants. Data were collected by using a pre-tested, self-administered, structured questionnaire and then it was cleaned, coded, entered in to Epidata v.3.2 and exported to SPSS version 25 statistical package for analysis. Multivariate logistic regression was used to identify the predictors of willingness to join and pay for Social Health Insurance. Odds ratio less than 0.05 was used as cut-off point and 95% CI was used to report the finding. Open question contingent valuation method was also used to analyze willingness to pay for the scheme.Result Among the total of 692 respondents, 254 (36.7%) were willing to join the scheme. Out of those who were willing to join 171 (24.7%) respondents were willing to pay less than 1% and 41(5.9%) respondents were willing to pay 2–3% of their gross monthly salary. Interest to join the scheme was found to be affected by an awareness of the scheme, household size, regularly listening for health information and participation in the social network.Conclusion There is limited knowledge and awareness about the design of health issuance. Majority of the respondents were not willing to join and pay the proposed amount for the scheme. Provision of health information on mass media could be used as one strategy to enhance the understanding of health insurance and to change perception on social health insurance scheme.

Background Ethiopia plans to introduce social health insurance scheme for the formal sector. The scheme contribution will be collected as 3% of an employee's monthly gross salary from both employee and employer. The scheme is expected to enhance access to health care, however, there is a concern that majority of civil servants were not willing to join and pay for it. Therefore, this study aims to assess willingness to join and pay for the newly proposed social health insurance among public servants in Arba Minch town, Southern Ethiopia.
Methods Institution based, Cross-sectional study design was used among 713 randomly selected public servants in Arba Minch town. Multi-stage stratified random sampling technique was used to select participants. Data were collected by using a pre-tested, self-administered, structured questionnaire and then it was cleaned, coded, entered in to Epidata v.3.2 and exported to SPSS version 25 statistical package for analysis. Multivariate logistic regression was used to identify the predictors of willingness to join and pay for Social Health Insurance. Odds ratio less than 0.05 was used as cut-off point and 95% CI was used to report the finding. Open question contingent valuation method was also used to analyze willingness to pay for the scheme.
Result Among the total of 692 respondents, 254 (36.7%) were willing to join the scheme. Out of those who were willing to join 171 (24.7%) respondents were willing to pay less than 1% and 41(5.9%) respondents were willing to pay 2-3% of their gross monthly salary. Interest to join the scheme was found to be affected by an awareness of the scheme, household size, regularly listening for health information and participation in the social network.
Conclusion There is limited knowledge and awareness about the design of health issuance. Majority of the respondents were not willing to join and pay the proposed amount for the scheme. Provision of health information on mass media could be used as one strategy to enhance the understanding of health insurance and to change perception on social health insurance scheme.

Background
In most of developing countries the out-of-pocket payment for health care service has been accounting for over 40% of their expenditure and that limits the poor from accessing the health care and leads to complicated health problems(1).
In Ethiopia, promising improvement was seen in the domestic share of health expenditure, yet household OOP (Out Of Pocket) spending (33%) remains a major domestic source. More than 73% of the population pay for health care from their OOP and the total per capita OOP expenditure of households for health is 231 ETB per year. As per above, the average per capita OOP is higher in urban than rural (2,3).
Moreover, there could be more unidentified gaps to achieve the social health insurance in Ethiopia in general and in Arba Minch town in particular. Thus, this study has been conducted with the aim of assessing willingness to join and pay for the newly proposed Social health insurance among public servants in Arba Minch town, Southern Ethiopia in order to provide recommendations for policy makers and planners to take in to consideration during their plan and implementation of Social health insurance of public servants.

Methods
Institution based, cross-sectional study was conducted from 1 st -30 th January 2019 in Gammo Zone, Arba Minch town, Southern Ethiopia. The town has four sub cities with total population projected to be 125, 411 of which close to 5, 281(4.2%) were public servants with no health insurance coverage (7).
To calculate the sample size, the prevalence was taken from a study conducted on willingness to join and pay for SHI scheme among teachers in Wolaita Sodo town in which 45% of participants were willing to join the scheme (6).Therefore, with 0.45 proportion, 95 % certainty and 5 % of margin of error between population and sample considering a design effect of 2 and an anticipated nonresponse rate of 10%, the total calculated sample size for this study was 713 public servants. Study participants who were permanent employees and Ethiopian citizens were eligible for the study.  Six grade 12 completed students and two private workers with a Bachelor's of any field in their academic achievements were recruited to facilitate the data collection and supervision respectively. Moreover, they were clearly briefed about the purpose of the study and an intensive training on the data collection methods was given for two days. A pretested, structured, anonymous, selfadministered questionnaire was used, the questionnaire was first prepared in English, translated to Amharic then back translated to English language for its consistency by two different individuals who speak both English and Amharic (the local language) fluently.
In order to ensure the quality of the data, pretesting of the questionnaire was done in the same set-up but not from a selected institution.
Some unclear and difficult questions to understand by most of the public servants were corrected accordingly during the pre-test. The principal investigator and supervisors supervised the data collection process. The questionnaires were checked for completeness and consistency in daily basis.
Data were entered in to Epi-data V3.2, edited and then exported to SPSS version 25 statistical packages for analysis then cleaned for inconsistencies and missing values. Assumptions for logistic regression and multi-collinearity diagnostics were checked. Descriptive statistics including frequencies, percentages, mean, and standard deviations were used to describe findings. The presence of association was assessed using bivariate analysis and associations with a p-value <0.05 considered statistically significant. Multivariate logistic regression was used to control confounding effects and the strength of association was estimated in odds ratio and its 95% confidence interval.
Variables with p-value <0.2 in the bivariate analysis were candidates for the final model.

Socio demographic characteristics of the respondents
Regarding educational status, more than half, 405(58.5%) were first degree and above holders and 360(52 %) of them were working in health facilities with mean service year of 9.5 +7.2 SD. From the total respondents, 78(11.3%) had legitimate authority in their working institution. and 33.1% don't have their own house (table 1).

Awareness and perception of SHI scheme
From the total respondents, 347(50.1 %) reported that they never heard about SHI before the time of data collection. Regarding the knowledge of SHI, more than one third, 270 (39%) knew about the benefit package of the SHI scheme (Table 3).

Willingness to join and pay for SHI
About one third, 254 (36.7%) of respondents were willing to join and pay for the newly proposed SHI (Fig 2). Among those who don't willing to join and pay for SHI, The main reason for not willing to join and pay for SHI were poor quality public health facility service, small monthly salary, lack of trust on the agency governing the contribution, Preference to use private health facilities and lack of enough information about SHI (Fig 3).

Discussion
The current study examines willingness to join and pay for the proposed Social Health Insurance scheme in Arba Minch town. Previous studies show that awareness and understanding of the concept of health insurance is positively associated with membership of a scheme (8). In this study, it is found that half of the respondents had never heard of the scheme. This finding similar with a study conducted at Woliata Sodo town (9). However, it is remarkably higher than studies conducted in Addis Ababa, Central Vietnam, rural population of Bangalore, India, Northwest Ethiopia, East Delhi, Andhra Pradesh and Nigeria (6,(10)(11)(12)(13)(14)(15)(16). This difference could be due to the difference in sociodemographic characteristics of the previous studies and the current study area; Addis Ababa, Vietnam, India and Nigeria might have high accessibility to get the information from different medias as compared to the current study area.
With regard to willingness, only one third of the respondents were willing to join and pay for the newly proposed SHI. This finding is higher than a study conducted in St. Paul's hospital Millennium Medical College, Addis Ababa, Ethiopia, in which only 17% of the respondents were willing to pay for the scheme (14). This gap might be related to difference in selection of study subjects. In the previous study, the study subjects were only health professionals which have different monthly income packages (allowances, top-up, overtime fees and other) besides their monthly salary. Therefore, they may have no significant shortage of money to pay for the scheme as compared to other employees.
In our case the study subjects were selected from different public servant groups with variable range of monthly income. On the other hand, the current finding is lower than studies conducted on government employees in Mekelle city, on teachers in Wolaita Sodo, on civil servants in Northwest Ethiopia, Kampala (Uganda), and Malaysia (9,10,(17)(18)(19)(20). Since awareness of the scheme drives for demand, this might be attributed to low awareness of the scheme in our study area.
Majority, two third were not willing to join the scheme in the current study. The main reason for not willing to join and pay for SHI were perceptions related to poor quality public health facility service, insufficient monthly salary, lack of trust on the agency governing the contribution, preference to use private health facilities and lack of enough information about SHI.
Among the respondents who were willing to join the scheme, only one fourth were willing to pay less than or equals to 1%, and few respondents were willing to pay 1-2 % and 2-3% of their gross monthly salary. This finding is consistent with a study conducted in Mekelle city, Northern Ethiopia (17).
Conversely, it is less than the finding seen on studies conducted in Wolaita Sodo and Vietnam (6,15), in which nearly half of the study participants were willing to pay 3% and 4% respectively. The gap might be linked directly or indirectly with awareness of the scheme, participants' professional background, net income and trust on the agency overseeing the scheme.
In the current study, adequate information about SHI, family size, active engagement on different social network were significantly associated with willingness to join and pay for the SIH scheme. It was found that participants with large family size were more likely willing to join than families with small family size. This finding is supported by studies conducted in Debrebrehan, Ethiopia, Nigeria, India and Uganda (8,9,20,21). Probably as family size increases, the probability of risk of illness will increase especially in the case of communicable illnesses. It could also be due to the increment of the health expenditure with family size in case of out-of-pocket payments that might drive for the family to impoverishment.
The likelihood of willing to join and pay for SHI is higher among public servants who heard about the scheme as compared to their counterparts. This finding is complemented by studies conducted on teachers' willingness to pay (WTP) in Wolaita Sodo, on civil servants' demand for SHI in Bahir Dar city and on knowledge and attitude of civil servants in Osun stata of Nigeria (10,15,22). Whenever there is better information and understanding about the scheme, people will be driven to choose joining SHI.
The other determinant factor for willingness to join and pay for SHI is social network participation; those who participate in social networks like "Eddire" and "Ekub"(local social gatherings in Ethiopia) were more likely to have willingness to join the scheme as compared to their counterparts. This finding is supported by a study conducted in Nigeria (21). This might be attributed to the fact that social network participation provides a good opportunity to discuss and share knowledge and experience among peers and other people in different social gatherings that fosters understanding of SHI.

Conclusion
The study revealed high level of public servants were not willing to join and pay for the newly proposed social health insurance scheme. The main reason for not willing to join and pay were poor quality health facility service, lack of trust on the agency governing the contribution, preference to private health facilities, insufficient monthly salary and lack of enough information about SHI.
Awareness of SHI, family size, regularly listening for health information and participation of social network were found to be independent predictors of willingness to join and pay for the social health insurance scheme. Awareness creation. Information, Education and Communication (IEC) about SHI to the public servants is highly required before implementation of the scheme. Ethical clearance was obtained from Addis Ababa University Ethical Review Committee. A formal letter was submitted to the Educational office of the Gammo Zone and subsequently to public sectors of Arba Minch town where the study took place. Oral and written permissions from the sectors and the respective study subjects were obtained. The study was explained to the subjects and their consent to participate in the study was assured before completing the questionnaire.

Availability of data and materials
The dataset supporting the conclusions of this article is included within the additional file.

Competing interests
We declare that we don't have any competing interests  Reason for not willing to join and pay for the newly proposed SHI among public servants in Arba Minch town.

Supplementary Files
This is a list of supplementary files associated with this preprint. Click to download. dataset.xls STROBEchecklistcrosssectional.doc