This study explored the willingness of the citizens of Saudi Arabia to pay for a contributory National Health Insurance. The results indicate that majority of Saudi citizens were willing to pay a monthly contribution for the National Health Insurance (NHI), if implemented, in return for a sustainable and improved quality of public healthcare services. This finding is consistent with previous studies that examined people’s willingness to pay for NHI in Jeddah city in Saudi Arabia [15, 16]. Our study provides evidence that citizens from other regions were also in favor of a NHI. People accepting NHI as an alternative financing mechanism might stems from the premise that this new system will improve the quality of public services as well as expand access to private facilities. The type of usual source of healthcare and satisfaction with the current healthcare services were found to have significant impact on the willingness to pay for NHI. People who usually used private health facilities were less likely to accept paying for an NHI. This was probably because they already had a private health insurance through their employer, so they did not see the need for a NHI. In Saudi Arabia, the employers in the private sector are required by law to provide their employees with health insurance. On the other hand, people who usually used public health facilities were more likely to accept paying for an NHI. This was probably because they wanted to expand their choices and access private providers. Saudi citizens have always perceived private hospital services as being of a better quality than those in public hospitals . Despite major investment in the public healthcare sector in Saudi Arabia by the government, many people remain dissatisfied with the availability and quality of care at publicly-run hospitals and clinics . The free model currently used in the public sector has led to longer waiting time and the overutilization of emergency departments . Increasing the involvement of the private sector through the NHI is an important approach that government is taking to decrease dependence on public funds and to improve the quality of care provided for NHI members. In addition to the type of usual source of care, the level of satisfaction with current health services was found to be a significant indicator of willingness to pay. People who were very satisfied with public services were more likely to accept contributing to NHI. This finding is consistent with a previous study that found that the respondents who were satisfied with the quality of public healthcare services were more willing to participate in NHI than those who were not . This is not surprising as people tend to pay for things they perceive as valuable and satisfactory and they believe their contribution is worthwhile. The hypothetical scenario presented to the respondents promised that the new NHI would help to sustain the level of health services currently provided, improve its quality, and expand access to private sector care.
The median amount that people were willing to pay as a monthly contribution for NHI was 100 SAR (26.5 USD) with the average being 152 SAR (40 USD). The rates currently applied in the private health insurance (citizens and non-citizens) fall in four categories, the highest with an average monthly rate of 167 Sar (44 USD), and the lowest at 71 SAR (19 USD) . So, it seems that the amount of money the respondents were willing to pay falls within the range of the rates currently used in the private insurance market. Two main factors, namely, income and age, were found to influence the maximum amount of money people were willing to pay for NHI. Higher-income individuals were more likely to pay a higher amount of money than low-income persons. This is expected as the higher the economic status, the more the individual would be able to pay insurance premiums compared to those with a low-level income. This is similar to previous studies that found higher-income individuals were more likely to participate in NHI [19–21]. Also, age was found to affect the maximum amount of money the individuals were willing to pay for NHI. It seems that young individuals were more likely to pay more money for NHI compared to older ones. This is consistent with other studies which found that age was a significant factor regarding the level of payment [21–24]. This is probably because the older people get, the more obligations they face which require dividing their limited resources carefully, while the younger people might have fewer financial responsibilities.
Almost one third of the study sample were unwilling to contribute to a national health insurance. Several reasons were provided. Almost half of these respondents stated that they believed it was the government's responsibility to provide free health services for the citizens. This is not surprising as most Saudi citizens consider healthcare to be a right and are accustomed to the free service model. Recently, however, the government has realized that this model is unsustainable in the long run. In spite of an increased budget allocation for free public health services, the actual average expenditure per capita is expected to decrease . This is because the population is rapidly growing and oil prices, from which most of the government revenues come, are fluctuating. Free healthcare has led to several problems such as overutilization and the abuse of services in addition to long waiting times and dissatisfaction with the quality of the services. Consequently, Saudi decision-makers are seeking to have a sustainable health system through the introduction of a contributory national health insurance. Other reasons for refusing to pay for NHI include some of the respondents not using public health services, and financial inability. More than half of the respondents who stated financial inability as their reason for not being willing to pay were unemployed or had monthly income less than 5000 SAR [Appendix 2], which may explain the lack of the means to contribute to a health insurance.
One of the limitations of the contingent valuation technique is based on whether it adequately measures people's willingness to pay for commodities which are not typically traded in the marketplace . Contingent valuation assumes that individuals understand the system service in question and will express their preferences in the contingent market just as they would in a real one. However, most people are unfamiliar with placing monetary values on services that are not typically traded in the marketplace. Therefore, they may not have had a suitable basis for expressing their true value. It is also suggested that people place a different value on a good in a hypothetical situation compared to an actual situation . Nevertheless, this study provides an exploration at the national level about the public’s willingness to pay for NHI, which should lead to further studies on the subject.