# Acceptance for Social Health Insurance among Health Professionals in Government Hospitals, Mekelle City, North Ethiopia

Authors: Alemtsehay Tewele; Mezgebu Yitayal; Adane Kebede
Journal: Advances in Public Health
 (2020)

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## Abstract

Background. Ethiopia is one of the countries with high out-of-pocket payments leading to catastrophic health expenditure. The government of Ethiopia introduced social health insurance (SHI) scheme with the overall objective of achieving universal health care access. Studying health professionals’ acceptance to pay for social health insurance is crucial for the successful implementation of the scheme. Therefore, this study aimed to assess the acceptance of social health insurance and its associated factors among health professionals in government hospitals, Mekelle city, North Ethiopia. Methods. An institution-based cross-sectional study design was used. The study participants were selected using systematic random sampling. Data were collected using a structured interviewer-administered questionnaire and analyzed using SPSS version 20. Bivariable and multivariable logistic regression models at a 5% level of significance, and odds ratios with 95% CI level were used to determine the association between the health professionals’ acceptance of health insurance and explanatory variables. Results. The study revealed that 62.5% of the respondents were willing to participate in the SHI scheme in which 74.9% were willing to pay 3% or more of their monthly salary. Health professionals’ acceptance for SHI significantly associated with monthly salary (AOR = 9.49; 95% CI: 2.51, 35.86), awareness about SHI (AOR = 3.89; 95% CI: 1.05, 14.28), history of difficulty in covering medical bills (AOR = 6.2; 95% CI: 2.42, 15.87), attitudes towards social health insurance (AOR = 7.57; 95% CI: 3.14, 18.21), and perceived quality of health care services if SHI implemented (AOR = 2.89; 95% CI: 1.18, 7.07). Conclusion. The study indicated that there were still a high proportion of health professionals who were not willing to pay for SHI. Therefore, strengthening awareness creation, creating awareness about SHI, promoting the scheme using the different channels of communication to bring about favorable attitude, and providing health care services with required standard quality could help to increase the acceptance of SHI by health professionals.


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## Body

## 1. Background

Social health insurance (SHI) is a health care funding mechanism that plays an important role in cross-subsidization and reducing the influence of high costs of health care [1]. It is characterized by compulsory universal coverage and financed by employers and individual contributions [1, 2]. Globally, 150 million people face financial catastrophe, and about 100 million people are pushed into poverty annually due to the need to pay for health services [3], and 90% of the people affected reside in low-income countries [4]. A survey of 89 countries indicate that 3%, 1.8%, and 0.6% of households face catastrophic health expenditure in low, middle-, and high-income countries, respectively [5]. Besides, a cross-sectional survey in Mongolia, Burkina Faso, and Uganda show that 5.5%, 15%, and 2.6% of households suffered from catastrophic health expenditures, respectively [6–8]. In Ethiopia, out-of-pocket spending is very high accounting for 37% of the total expenditure in the health sector [9].A systematic review of WTP for health insurance from ten countries in low- and middle-income countries showed that the mean WTP of individuals and households is 1.18% and 1.82% of GDP per capita and 1.39% and 2.16% of adjusted net national income per capita, respectively [10]. Studies indicate that the average WTP for SHI per person per month in Iran was 5.5 $US [11], and households in Vietnam are willing to pay 4% of their income for health insurance [12]. In Malaysia, 72.5% of the academic staff are willing to pay an average of RM 79.32 per month per household [13], and 71.2% of patients attending specialist clinics supported the proposed NHI and 61.4% are willing to pay up to $ 192 per year [14].In Africa, studies indicate that 30% of households in South Africa [15], 90% of households in Ghana [16], 87% of the uninsured respondents in Namibia [17], and 52.5% of civil servants (18) and 89% of households in Nigeria [18] are willing to pay for health insurance schemes. Besides, 63.6% of households in Ghana and 43.8% of households in Nigeria are willing to pay a premium of $3.03 a month [16] and 5% mandatory premium [18], respectively. Households in Ghana are also willing to pay 1.9%–2.5% of their income for health insurance [16]. In Ethiopia, studies indicate that 69.8% of civil servants in Debre Markos [19] and 71.3% of teachers in Wolaita Sodo [20] are willing to pay the proposed premium (3% of their salary) for SHI.Evidence shows that sociodemographic and economic factors such as the age of household head [10, 16, 21], sex [17, 21–23], level of education [11, 24], family size [10, 11, 25], and economic status of the households [16, 26, 27]; health and health-related factors such as health status [20, 25, 28, 29]; and awareness, knowledge, and attitude towards health insurance schemes [14, 20, 30] determine the acceptance of SHI. However, there is limited evidence in the study area. Therefore, this study aimed to assess the acceptance of SHI and its associated factors among health professionals in government hospitals, Mekelle city, Ethiopia.


## 2. Methods

### 2.1. Study Design and Setting

An institution-based cross-sectional study design was used to assess acceptance for social health insurance and its associated factors among health professionals in Mekelle city. The study was conducted in Mekelle city which is 783 km away from Addis Ababa, the capital city of Ethiopia. According to the 2007 Census, the town has a total population of 273,000. Administratively, it is divided into seven subadministrative units. According to the Mekelle City Health Office report in 2016, the city has one Teaching Referral Hospital and two General Hospitals staffed with 1,440 health professionals.


### 2.2. Study Population and Sampling Procedures

The source population of this study was all health professionals in the government hospitals in Mekelle city. The study population of this study was health professionals from randomly selected government hospitals. All health professionals who have served at least 3 months were included in the study. All health professionals who were expatriates were excluded from the study.The sample size was determined using single population proportion formula by taking 53% of the health professionals are willing to pay for SHI [20], 5% margin of error, 95% CI, and 10% nonresponse rate.N = (Zα/2)2 × p × [1-p]/w2 = (1.96)2 × 0.53 × (1–0.53)/0.0025 = 382.78The final sample size was 382.78 + 38.28 (response rate) = 421.06 ≈ 421.Three government hospitals in the study area were included in the study, and a list of the health professionals was obtained from the three hospitals. The sample was allocated to each hospital proportional to the number of health professionals in each hospital, and a systematic random sampling technique with a sampling interval of 3 was used to select the study participants.


### 2.3. Study Variables

#### 2.3.1. Response Variable

The response variable of the study was the acceptance of SHI among health professionals. Acceptance of SHI was measured by asking the respondents “Are you willing to pay for SHI? The alternative options were “Yes” if respondents were willing to pay 3% and above of monthly salary or “No” if respondents were not willing to pay at least 3% of their monthly salary. The 3% premium was set by the government of Ethiopia to implement the SHI [31].


#### 2.3.2. Explanatory Variables

The sociodemographic and economic factors (age, sex, education, marital status, family size, children <5, adults >64 years, monthly salary, and wealth status); health and health-related factors (perceived health status, presence of chronic disease, history of illness within 6 months of the survey, history of difficulty covering the medical bill); and health insurance-related factors (awareness or ever heard about SHI, knowledge, attitude toward social health insurance and health insurance experiences) were the explanatory variables.


#### 2.3.3. Knowledge of SHI

Knowledge of study participants about SHI was assessed by asking them a set of 10 questions about social health insurance, and the right answer was given a value of 1 and 0 for those incorrect answers. Respondents who had a score greater than or equal to the mean score were considered as good knowledge about SHI unless as poor [14].


#### 2.3.4. Attitude towards SHI

Attitude was defined as what the health professionals think or feel about SHI and measured using 6 questions: (1) the proclamation of SHI by the Ethiopian government is good; (2) social health insurance is very important; (3) redistribution of health care cost from sick to healthy is good; (4) the arrangement of making monthly deduction from salary for SHI is good; (5) social health insurance should be made compulsory; and (6) social health insurance is a program that should be initiated and sustained. Each question contains five points Likert scales (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree). Those who had a mean score greater than 3 were considered as having a positive/favorable attitude otherwise negative/unfavorable [32].


#### 2.3.5. Wealth Status

The wealth status of study participants was assessed based on housing condition and durable assets and divided into three equal parts: low-, middle-, and high-wealth status.


### 2.4. Data Collection Procedures

A structured interviewer-administered questionnaire was developed by reviewing the literature on acceptance of health insurance [10, 11, 13, 20, 27–30, 33, 34]. It had closed-ended questions consisting of sociodemographic characteristics, economic status, health status, knowledge and attitude, and acceptance of SHI. For data collection, six students supervised by two senior nurses were assigned with the principal investigator’s critical follow up. The data collectors and supervisors were approached by the principal investigator and took the data collection training if they agreed to participate in the data collection process. The data collectors and supervisors were trained for two days on data collection procedures.A pretest was conducted on 21 (5% of the sample) health professionals in Wukro hospital, and necessary modification was done after the pretest. Then, in the final data collection, the study participants assisted by the data collectors filled in the questionnaire. The collected data were checked by the data collectors’ supervisors as well as the principal investigator.


### 2.5. Data Processing and Analysis

Data were entered into Epi Info version 3.5.1 and exported to Statistical Package for Social Sciences (SPSS) version 20 for analysis. Data were cleaned and coded before entry. Descriptive statistics like percentage, frequency, mean, median, standard deviation, and IQR were used to show a clear picture of the characteristics of the respondents. For describing wealth status, principal component analysis (PCA) was used and divided into three equal parts (three tiles) as low-, middle-, and high-wealth status. Initially, bivariable logistic regression at ap value of less than 0.25 was used to identify factors independently associated with the outcome variable. Then to control the effect of confounding, multivariable logistic regression analysis was done. Statistical significance was determined using 5% of the level of significance and odds ratio with 95% CI.


## 2.1. Study Design and Setting

An institution-based cross-sectional study design was used to assess acceptance for social health insurance and its associated factors among health professionals in Mekelle city. The study was conducted in Mekelle city which is 783 km away from Addis Ababa, the capital city of Ethiopia. According to the 2007 Census, the town has a total population of 273,000. Administratively, it is divided into seven subadministrative units. According to the Mekelle City Health Office report in 2016, the city has one Teaching Referral Hospital and two General Hospitals staffed with 1,440 health professionals.


## 2.2. Study Population and Sampling Procedures

The source population of this study was all health professionals in the government hospitals in Mekelle city. The study population of this study was health professionals from randomly selected government hospitals. All health professionals who have served at least 3 months were included in the study. All health professionals who were expatriates were excluded from the study.The sample size was determined using single population proportion formula by taking 53% of the health professionals are willing to pay for SHI [20], 5% margin of error, 95% CI, and 10% nonresponse rate.N = (Zα/2)2 × p × [1-p]/w2 = (1.96)2 × 0.53 × (1–0.53)/0.0025 = 382.78The final sample size was 382.78 + 38.28 (response rate) = 421.06 ≈ 421.Three government hospitals in the study area were included in the study, and a list of the health professionals was obtained from the three hospitals. The sample was allocated to each hospital proportional to the number of health professionals in each hospital, and a systematic random sampling technique with a sampling interval of 3 was used to select the study participants.


## 2.3. Study Variables

### 2.3.1. Response Variable

The response variable of the study was the acceptance of SHI among health professionals. Acceptance of SHI was measured by asking the respondents “Are you willing to pay for SHI? The alternative options were “Yes” if respondents were willing to pay 3% and above of monthly salary or “No” if respondents were not willing to pay at least 3% of their monthly salary. The 3% premium was set by the government of Ethiopia to implement the SHI [31].


### 2.3.2. Explanatory Variables

The sociodemographic and economic factors (age, sex, education, marital status, family size, children <5, adults >64 years, monthly salary, and wealth status); health and health-related factors (perceived health status, presence of chronic disease, history of illness within 6 months of the survey, history of difficulty covering the medical bill); and health insurance-related factors (awareness or ever heard about SHI, knowledge, attitude toward social health insurance and health insurance experiences) were the explanatory variables.


### 2.3.3. Knowledge of SHI

Knowledge of study participants about SHI was assessed by asking them a set of 10 questions about social health insurance, and the right answer was given a value of 1 and 0 for those incorrect answers. Respondents who had a score greater than or equal to the mean score were considered as good knowledge about SHI unless as poor [14].


### 2.3.4. Attitude towards SHI

Attitude was defined as what the health professionals think or feel about SHI and measured using 6 questions: (1) the proclamation of SHI by the Ethiopian government is good; (2) social health insurance is very important; (3) redistribution of health care cost from sick to healthy is good; (4) the arrangement of making monthly deduction from salary for SHI is good; (5) social health insurance should be made compulsory; and (6) social health insurance is a program that should be initiated and sustained. Each question contains five points Likert scales (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree). Those who had a mean score greater than 3 were considered as having a positive/favorable attitude otherwise negative/unfavorable [32].


### 2.3.5. Wealth Status

The wealth status of study participants was assessed based on housing condition and durable assets and divided into three equal parts: low-, middle-, and high-wealth status.


## 2.3.1. Response Variable

The response variable of the study was the acceptance of SHI among health professionals. Acceptance of SHI was measured by asking the respondents “Are you willing to pay for SHI? The alternative options were “Yes” if respondents were willing to pay 3% and above of monthly salary or “No” if respondents were not willing to pay at least 3% of their monthly salary. The 3% premium was set by the government of Ethiopia to implement the SHI [31].


## 2.3.2. Explanatory Variables

The sociodemographic and economic factors (age, sex, education, marital status, family size, children <5, adults >64 years, monthly salary, and wealth status); health and health-related factors (perceived health status, presence of chronic disease, history of illness within 6 months of the survey, history of difficulty covering the medical bill); and health insurance-related factors (awareness or ever heard about SHI, knowledge, attitude toward social health insurance and health insurance experiences) were the explanatory variables.


## 2.3.3. Knowledge of SHI

Knowledge of study participants about SHI was assessed by asking them a set of 10 questions about social health insurance, and the right answer was given a value of 1 and 0 for those incorrect answers. Respondents who had a score greater than or equal to the mean score were considered as good knowledge about SHI unless as poor [14].


## 2.3.4. Attitude towards SHI

Attitude was defined as what the health professionals think or feel about SHI and measured using 6 questions: (1) the proclamation of SHI by the Ethiopian government is good; (2) social health insurance is very important; (3) redistribution of health care cost from sick to healthy is good; (4) the arrangement of making monthly deduction from salary for SHI is good; (5) social health insurance should be made compulsory; and (6) social health insurance is a program that should be initiated and sustained. Each question contains five points Likert scales (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree). Those who had a mean score greater than 3 were considered as having a positive/favorable attitude otherwise negative/unfavorable [32].


## 2.3.5. Wealth Status

The wealth status of study participants was assessed based on housing condition and durable assets and divided into three equal parts: low-, middle-, and high-wealth status.


## 2.4. Data Collection Procedures

A structured interviewer-administered questionnaire was developed by reviewing the literature on acceptance of health insurance [10, 11, 13, 20, 27–30, 33, 34]. It had closed-ended questions consisting of sociodemographic characteristics, economic status, health status, knowledge and attitude, and acceptance of SHI. For data collection, six students supervised by two senior nurses were assigned with the principal investigator’s critical follow up. The data collectors and supervisors were approached by the principal investigator and took the data collection training if they agreed to participate in the data collection process. The data collectors and supervisors were trained for two days on data collection procedures.A pretest was conducted on 21 (5% of the sample) health professionals in Wukro hospital, and necessary modification was done after the pretest. Then, in the final data collection, the study participants assisted by the data collectors filled in the questionnaire. The collected data were checked by the data collectors’ supervisors as well as the principal investigator.


## 2.5. Data Processing and Analysis

Data were entered into Epi Info version 3.5.1 and exported to Statistical Package for Social Sciences (SPSS) version 20 for analysis. Data were cleaned and coded before entry. Descriptive statistics like percentage, frequency, mean, median, standard deviation, and IQR were used to show a clear picture of the characteristics of the respondents. For describing wealth status, principal component analysis (PCA) was used and divided into three equal parts (three tiles) as low-, middle-, and high-wealth status. Initially, bivariable logistic regression at ap value of less than 0.25 was used to identify factors independently associated with the outcome variable. Then to control the effect of confounding, multivariable logistic regression analysis was done. Statistical significance was determined using 5% of the level of significance and odds ratio with 95% CI.


## 3. Results

### 3.1. Demographic and Socioeconomic Characteristics of the Respondents

A total of 408 health professionals participated in the study with a response rate of 97%. The study revealed that 50.2% were males, 92% were Tigrie, 85.7% were Orthodox Christians, 54.4% were married, and 68.6% had family size ≤ 3. Majority (57.1%) of the study participants were nurses followed by physicians (15.2%). The mean age of respondents was 32 ± 6.7 years (Table1).Table 1
Sociodemographic and economic characteristics of health professionals in government hospitals, Mekelle city, North Ethiopia, 2017 (N = 408).
Variables
Category
Frequency (n = 408)
Percentage (%)
Sex
Male
205
50.2
Female
203
49.8
Age
20–30
220
53.9
31–40
146
35.8
Mean age ± SD
≥41
42
10.3
32 ± 6.7
Ethnicity
Tigrie
372
91.1
Amhara
17
4.2
Others
19
4.7
Religion
Orthodox
353
85.7
Muslim
33
8
Others
22
5.3
Marital status
Single
168
41.2
Married
222
54.4
Others
18
4.4
Family size
1–3
280
68.6
≥4
128
31.4
Children <5
Yes
142
65.2
No
266
34.8
Adults >64
Yes
19
4.7
No
389
95.3
Professions
Physician
62
15.2
Pharmacist
37
9.1
Nurse
233
57.1
Midwifery
22
5.4
Medical laboratory
29
7.1
Physiotherapy
7
1.7
Others
18
4.4
Level of education
Diploma
44
10.8
Degree
328
80.4
Masters
18
4.4
Specialist
18
4.4
Work experiences in years
1–5
246
60.3
6–10
101
24.7
≥11
61
15
Median (IQR)
5 (4)
Monthly salary
<6488 ETB
229
56.1
6488-10024 ETB
131
32.1
≥10024 ETB
48
11.8
Median (IQR) ETB
6488 (3119)
Wealth status
Low
135
33.1
Middle
150
36.8
High
123
30.1


### 3.2. Health and Health-Related Characteristics of the Respondents

Out of 408 health professionals participated, 87.5% perceived their health status (self-rated health status) as good, 10.5% had a chronic medical illness, 18.4% had a history of at least one episode of illness within six months of the survey, and 99% got treated of them 78% was treated in government health institutions. Regarding medical bills of treatment, 75.6% of those who had a history of illness within six months of the survey were treated freely and 20.1% of study participants ever had a history of covering medical bills (Figure1).Figure 1
Medical bills of treatment among health professionals in government hospitals, Mekelle City, North Ethiopia, 2017.


### 3.3. Awareness, Knowledge, and Attitudes about Social Health Insurance

The study revealed that 84.8% of the respondents ever heard about SHI, and the source of information was media (39.8%), conferences/meetings (29.1%), colleagues (16.1%), and friends and patients (14%). Only 6.6% of the respondents had any form of health insurance previously. The mean score of respondents on knowledge about SHI was 4.5 ± 2.76, and 59.3% of the respondents had good knowledge about SHI, 64% of the respondents had a positive attitude towards SHI, and 50% of the respondents had a good perception about the quality of health care services if SHI implemented.


### 3.4. Acceptance of Social Health Insurance

The study indicated that 62.5% of the respondents were willing to participate in the scheme of which 74.9% were willing to pay 3% or more of their monthly salary. The median (IQR) of maximum willingness to pay was 3% [1] of monthly salary (Table 2). The main reasons for not accepting or not willing to participate in the SHI scheme were the respondents’ perceptions that the government is responsible to finance SHI and health care services should be free for health professionals because they are at risk for infection (Figure 2).Table 2
Health professionals’ acceptance for social health insurance in government hospitals, Mekelle City, North Ethiopia, 2017.
Variables
Category
Frequency
Percentage (%)
Willing to participate in SHI (n = 408)
Yes
255
62.5
No
153
37.5
WTP <3% of monthly salary (n = 408)
217
53.2
WTP <3% of monthly salary (n = 255)
64
25.1
WTP >3% of monthly salary (n = 408)
191
46.8
WTP >3% of monthly salary (n = 255)
191
74.9
Median of maximum willing to pay with IQR (%)
3 (1)%Figure 2
Reasons for not accepting social health insurance among health professionals in government hospitals, Mekelle City, North Ethiopia, 2017.


### 3.5. Factors Associated with Acceptance of Social Health Insurance

The study revealed that monthly salary, history of difficulty of covering medical bills, awareness (ever heard) about SHI, attitudes towards SHI, and perceived quality health care services if SHI implemented were the factors statistically associated with acceptance (willing to pay) SHI among health professionals.The health professionals who earn ≥10024 ETB monthly salary were 9.49 (AOR = 9.49; 95% CI: 2.51, 35.86) times more likely to be willing to pay for SHI than those who earn <6488 ETB. Respondents that ever had a history of difficulty of covering medical bills were 6.2 (AOR = 6.2; 95% CI: 2.42, 15.87) times more likely to be willing to pay compared with those who did not have. Study participants whoever heard about SHI were 3.89 (AOR = 3.89; 95% CI: 1.05, 14.28) times more likely to be willing to pay for SHI than those never heard. Health professionals with positive attitudes were 7.57 (AOR = 7.57; 95% CI: 3.14, 18.21) times more likely to be willing to pay than those with unfavorable attitudes. Regarding the perceived quality of health care services, those who perceived as good were 2.89 (AOR = 2.89; 95%: CI: 1.18, 7.07) times more likely and those who perceived as poor were 81% (AOR = 0.19; 95% CI: 0.06, 0.59) times less likely to be willing to pay compared with those with neutral perception (Table3).Table 3
Factors associated with acceptance for social health insurance among health professionals in government hospitals, Mekelle city, North Ethiopia, 2017.
Variables
WTP
COR (95%CI)
AOR (95%CI)
Yes
No
Sex
Male
95
110
1
Female
96
107
1.039 (0.70, 1.53)
Age
1.121 (1.08, 1.16)∗
1.029 (0.95, 1.11)
Marital status
Married
134
88
3.44 (2.28, 5.20)∗
1.54 (0.66, 3.58)
Other than married
57
129
1
Family size
1-3
105
175
1
1
≥4
86
42
3.41 (2.19, 5.30)∗
1.72 (0.62, 4.78)
Children <5 years
Yes
103
39
5.34 (3.41, 8.36)∗
2.55 (0.95, 5.34)
No
88
178
1
1
Adults >64
Yes
14
5
3.35 (1.18, 9.49)∗
1.33 (0.29, 6.05)
No
177
212
1
1
Level of education
Diploma
6
38
1
1
Degree and above
185
179
6.54 (2.70, 15.86)∗
1.32 (0.39, 4.47)
Monthly salary
0-6488 ETB
70
159
1
1
6488-10024 ETB
79
52
3.45 (2.20, 5.40)∗
1.16 (0.56, 2.607)
≥10024 ETB
42
6
15.9 (6.48, 39.12)∗
9.49 (2.51, 35.86)∗∗
Wealth status
Low
64
71
1
Middle
68
82
0.92 (0.57, 1.46)
High
59
64
1.02 (0.62, 1.66)
Perceived health status
Good
165
192
1
1
Fair
16
22
0.84 (0.43, 1.66)
0.39 (0.11, 1.35)
Poor
10
3
3.87 (1.05, 14.33)∗
1.56 (0.14, 17.44)
Chronic medical illness
Yes
32
11
3.76 (1.84, 7.70)∗
2.43 (0.67, 8.80)
No
159
206
1
1
History of illness in the previous 6 months
Yes
42
33
1.57 (0.94, 2.60)
No
149
184
1
History of difficulty covering medical bills
Yes
61
21
4.37 (2.54, 7.53)∗
6.2 (2.42, 15.87)∗∗
No
130
196
1
1
Ever heard about SHI
Yes
185
161
10.72 (4.50, 25.54)∗
3.89 (1.05, 14.28)∗∗
No
6
56
1
1
Have/had health insurance
Yes
18
5
4.41 (1.60, 12.12)∗
1.98 (0.44, 8.99)
No
173
212
1
1
Knowledge about SHI
Poor
29
137
1
1
Good
162
80
9.56 (5.90, 15.48)∗
0.77 (0.32, 1.85)
Attitude toward SHI
Positive/favorable
180
81
27.47 (14.08, 53.58)∗
7.57 (3.14, 18.21)∗∗
Negative/unfavorable
11
136
1
1
Perceived quality of services if SHI is implemented
Poor
11
103
0.44 (0.19, 0.99)∗
0.19 (0.06, 0.59)∗∗
Good
163
44
15.25 (8.15, 28.52)∗
2.89 (1.18, 7.07)∗∗
Neutral
17
70
1
1
∗Statistically significant results at p value<0.25; ∗∗statistically significant results at p value<0.05; 1: reference category; COR: crude odds ratio; AOR: adjusted odds ratio.


## 3.1. Demographic and Socioeconomic Characteristics of the Respondents

A total of 408 health professionals participated in the study with a response rate of 97%. The study revealed that 50.2% were males, 92% were Tigrie, 85.7% were Orthodox Christians, 54.4% were married, and 68.6% had family size ≤ 3. Majority (57.1%) of the study participants were nurses followed by physicians (15.2%). The mean age of respondents was 32 ± 6.7 years (Table1).Table 1
Sociodemographic and economic characteristics of health professionals in government hospitals, Mekelle city, North Ethiopia, 2017 (N = 408).
Variables
Category
Frequency (n = 408)
Percentage (%)
Sex
Male
205
50.2
Female
203
49.8
Age
20–30
220
53.9
31–40
146
35.8
Mean age ± SD
≥41
42
10.3
32 ± 6.7
Ethnicity
Tigrie
372
91.1
Amhara
17
4.2
Others
19
4.7
Religion
Orthodox
353
85.7
Muslim
33
8
Others
22
5.3
Marital status
Single
168
41.2
Married
222
54.4
Others
18
4.4
Family size
1–3
280
68.6
≥4
128
31.4
Children <5
Yes
142
65.2
No
266
34.8
Adults >64
Yes
19
4.7
No
389
95.3
Professions
Physician
62
15.2
Pharmacist
37
9.1
Nurse
233
57.1
Midwifery
22
5.4
Medical laboratory
29
7.1
Physiotherapy
7
1.7
Others
18
4.4
Level of education
Diploma
44
10.8
Degree
328
80.4
Masters
18
4.4
Specialist
18
4.4
Work experiences in years
1–5
246
60.3
6–10
101
24.7
≥11
61
15
Median (IQR)
5 (4)
Monthly salary
<6488 ETB
229
56.1
6488-10024 ETB
131
32.1
≥10024 ETB
48
11.8
Median (IQR) ETB
6488 (3119)
Wealth status
Low
135
33.1
Middle
150
36.8
High
123
30.1


## 3.2. Health and Health-Related Characteristics of the Respondents

Out of 408 health professionals participated, 87.5% perceived their health status (self-rated health status) as good, 10.5% had a chronic medical illness, 18.4% had a history of at least one episode of illness within six months of the survey, and 99% got treated of them 78% was treated in government health institutions. Regarding medical bills of treatment, 75.6% of those who had a history of illness within six months of the survey were treated freely and 20.1% of study participants ever had a history of covering medical bills (Figure1).Figure 1
Medical bills of treatment among health professionals in government hospitals, Mekelle City, North Ethiopia, 2017.


## 3.3. Awareness, Knowledge, and Attitudes about Social Health Insurance

The study revealed that 84.8% of the respondents ever heard about SHI, and the source of information was media (39.8%), conferences/meetings (29.1%), colleagues (16.1%), and friends and patients (14%). Only 6.6% of the respondents had any form of health insurance previously. The mean score of respondents on knowledge about SHI was 4.5 ± 2.76, and 59.3% of the respondents had good knowledge about SHI, 64% of the respondents had a positive attitude towards SHI, and 50% of the respondents had a good perception about the quality of health care services if SHI implemented.


## 3.4. Acceptance of Social Health Insurance

The study indicated that 62.5% of the respondents were willing to participate in the scheme of which 74.9% were willing to pay 3% or more of their monthly salary. The median (IQR) of maximum willingness to pay was 3% [1] of monthly salary (Table 2). The main reasons for not accepting or not willing to participate in the SHI scheme were the respondents’ perceptions that the government is responsible to finance SHI and health care services should be free for health professionals because they are at risk for infection (Figure 2).Table 2
Health professionals’ acceptance for social health insurance in government hospitals, Mekelle City, North Ethiopia, 2017.
Variables
Category
Frequency
Percentage (%)
Willing to participate in SHI (n = 408)
Yes
255
62.5
No
153
37.5
WTP <3% of monthly salary (n = 408)
217
53.2
WTP <3% of monthly salary (n = 255)
64
25.1
WTP >3% of monthly salary (n = 408)
191
46.8
WTP >3% of monthly salary (n = 255)
191
74.9
Median of maximum willing to pay with IQR (%)
3 (1)%Figure 2
Reasons for not accepting social health insurance among health professionals in government hospitals, Mekelle City, North Ethiopia, 2017.


## 3.5. Factors Associated with Acceptance of Social Health Insurance

The study revealed that monthly salary, history of difficulty of covering medical bills, awareness (ever heard) about SHI, attitudes towards SHI, and perceived quality health care services if SHI implemented were the factors statistically associated with acceptance (willing to pay) SHI among health professionals.The health professionals who earn ≥10024 ETB monthly salary were 9.49 (AOR = 9.49; 95% CI: 2.51, 35.86) times more likely to be willing to pay for SHI than those who earn <6488 ETB. Respondents that ever had a history of difficulty of covering medical bills were 6.2 (AOR = 6.2; 95% CI: 2.42, 15.87) times more likely to be willing to pay compared with those who did not have. Study participants whoever heard about SHI were 3.89 (AOR = 3.89; 95% CI: 1.05, 14.28) times more likely to be willing to pay for SHI than those never heard. Health professionals with positive attitudes were 7.57 (AOR = 7.57; 95% CI: 3.14, 18.21) times more likely to be willing to pay than those with unfavorable attitudes. Regarding the perceived quality of health care services, those who perceived as good were 2.89 (AOR = 2.89; 95%: CI: 1.18, 7.07) times more likely and those who perceived as poor were 81% (AOR = 0.19; 95% CI: 0.06, 0.59) times less likely to be willing to pay compared with those with neutral perception (Table3).Table 3
Factors associated with acceptance for social health insurance among health professionals in government hospitals, Mekelle city, North Ethiopia, 2017.
Variables
WTP
COR (95%CI)
AOR (95%CI)
Yes
No
Sex
Male
95
110
1
Female
96
107
1.039 (0.70, 1.53)
Age
1.121 (1.08, 1.16)∗
1.029 (0.95, 1.11)
Marital status
Married
134
88
3.44 (2.28, 5.20)∗
1.54 (0.66, 3.58)
Other than married
57
129
1
Family size
1-3
105
175
1
1
≥4
86
42
3.41 (2.19, 5.30)∗
1.72 (0.62, 4.78)
Children <5 years
Yes
103
39
5.34 (3.41, 8.36)∗
2.55 (0.95, 5.34)
No
88
178
1
1
Adults >64
Yes
14
5
3.35 (1.18, 9.49)∗
1.33 (0.29, 6.05)
No
177
212
1
1
Level of education
Diploma
6
38
1
1
Degree and above
185
179
6.54 (2.70, 15.86)∗
1.32 (0.39, 4.47)
Monthly salary
0-6488 ETB
70
159
1
1
6488-10024 ETB
79
52
3.45 (2.20, 5.40)∗
1.16 (0.56, 2.607)
≥10024 ETB
42
6
15.9 (6.48, 39.12)∗
9.49 (2.51, 35.86)∗∗
Wealth status
Low
64
71
1
Middle
68
82
0.92 (0.57, 1.46)
High
59
64
1.02 (0.62, 1.66)
Perceived health status
Good
165
192
1
1
Fair
16
22
0.84 (0.43, 1.66)
0.39 (0.11, 1.35)
Poor
10
3
3.87 (1.05, 14.33)∗
1.56 (0.14, 17.44)
Chronic medical illness
Yes
32
11
3.76 (1.84, 7.70)∗
2.43 (0.67, 8.80)
No
159
206
1
1
History of illness in the previous 6 months
Yes
42
33
1.57 (0.94, 2.60)
No
149
184
1
History of difficulty covering medical bills
Yes
61
21
4.37 (2.54, 7.53)∗
6.2 (2.42, 15.87)∗∗
No
130
196
1
1
Ever heard about SHI
Yes
185
161
10.72 (4.50, 25.54)∗
3.89 (1.05, 14.28)∗∗
No
6
56
1
1
Have/had health insurance
Yes
18
5
4.41 (1.60, 12.12)∗
1.98 (0.44, 8.99)
No
173
212
1
1
Knowledge about SHI
Poor
29
137
1
1
Good
162
80
9.56 (5.90, 15.48)∗
0.77 (0.32, 1.85)
Attitude toward SHI
Positive/favorable
180
81
27.47 (14.08, 53.58)∗
7.57 (3.14, 18.21)∗∗
Negative/unfavorable
11
136
1
1
Perceived quality of services if SHI is implemented
Poor
11
103
0.44 (0.19, 0.99)∗
0.19 (0.06, 0.59)∗∗
Good
163
44
15.25 (8.15, 28.52)∗
2.89 (1.18, 7.07)∗∗
Neutral
17
70
1
1
∗Statistically significant results at p value<0.25; ∗∗statistically significant results at p value<0.05; 1: reference category; COR: crude odds ratio; AOR: adjusted odds ratio.


## 4. Discussion

This study showed that 62.5% of the respondents were willing to participate in the SHI which is lower than studies done in Nigeria [35], Ghana [16], and Eastern Caribbean [33] where 83.9%, 90%, and 69.5% are willing to participate in SHI scheme, respectively. This may be due to the difference in the insurance experiences and premium collection approach. For Example, in Ghana, the formal sector shall contribute 2.5% of their 17.5% Social Security and National Insurance Trust (SSNIT) contribution. The contribution levels have an inbuilt cross-subsidization mechanism, whereby the rich pay more than the less privileged, adults pay on behalf of children, the healthy cover for the sick, and urban dwellers pay more than the rural dwellers [36], whereas in Ethiopia, the formal sector shall contribute 3% per month from the net salary and its similar for all employee [31].In this study, 46.8% were willing to pay greater than or equal to 3% of monthly salary which is lower than the finding of a study conducted in Debre Markos, where 68.9% are willing to pay 3% of monthly salary for SHI scheme. This disparity could be due to the difference in the burden of medical bills when seeking health care services [34].The Median (IQR) maximum premium among those who were willing to participate was 3% (1) of monthly salary which is in line with the premium proposed by the Ethiopian government [31] and a study conducted in Addis Ababa city [30]. However, it is lower that of than a study conducted in Vietnam where respondents are willing to pay 4% of their income for SHI [12], and it is higher than the finding from Ghana [16]. This could be due to the socioeconomic differences among countries.The results of this study showed that respondents with high monthly salaries were more likely to be willing to pay for SHI. This could be due to their ability to afford health insurance premiums and contribution for SHI being progressive is good. This finding is in line with the findings of studies done in Addis Ababa [29], Cameron [37], and Selangor state, Malaysia [38]. However, it contradicts a study conducted in Malaysia where those with lower salaries are more willing to pay compared with those with a higher salary. This could be due to better income that results in better health status, and this lowers the demand for health insurance [13]. In Malaysia, government-subsidized insurance schemes purchased based on each person’s ability to pay [39] and people with a high salary might prefer private health care insurance.Respondents who had previous financial problems to cover medical bills were more likely willing to pay for SHI. This is consistent with findings in rural China which indicate that individuals who worry about medical expenditure are more willing to pay for health insurance than those who do not [28]. It is also consistent with studies done in Ghana [16] and Wolaita Sodo, Ethiopia [20].Health professionals whoever heard (aware) about SHI were more likely to be willing to pay than those who never heard. This finding is consistent with findings from Ebonyi State, Nigeria [40] and Central Vietnam [12]. This could be health professionals whoever heard about SHI are aware of the benefits of having health insurance.Regarding attitude, respondents with a favorable attitude were more likely to be willing to pay than those with unfavorable attitudes. This is consistent with the finding of a study conducted in southwestern Nigeria [34]. This study revealed that perception about the quality of health care services if SHI implemented was positively associated with acceptance of SHI. This is similar to the result of research done in Debre Markos [19].The main reason mentioned by respondents for not willing to participate was that the respondents thought it as the government’s responsibility to finance for SHI and health care services should be free for health professionals. This is similar to a study conducted in Malaysia in which the main reason is that health care services should be provided free of charge and subsidized fully by the government [38].In this study, health-related factors like perceived health status, chronic medical illness, and history of illness were not statistically significant. This could be due to less financial burden for seeking treatment as most health professionals in the study area have privileged access and may get health services freely.


## 5. Limitations of the study

This study could not show the temporal relationship between acceptance for SHI and explanatory variables due to the nature of the study design. Another limitation of this study could be social desirability bias in which health professionals may tend to give favorable responses as they are the main stakeholders for sensitizing and implementing health-related policies such as SHI.


## 6. Conclusion

The study indicated that nearly two-thirds of the study participants were willing to participate in the SHI. However, there was still a high proportion of health professionals who were not willing to pay for SHI. Monthly salary, having a history of difficulty in covering medical bills, awareness about and attitude towards SHI, and perceived quality of services if SHI is implemented are factors significantly associated with health professionals’ acceptance of SHI. Therefore, strengthening awareness creation, creating awareness about SHI, promoting the scheme using a different channel of communication to bring about favorable attitude, and providing health care services with required standard quality could help to increase the acceptance of SHI by health professionals.



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*Source: 6458425-2020-05-06.xml*