Are People Able and Willing to Pay for CBHI Membership in Ethiopia? National Household Survey

Abstract

Abstract Background The existing evidence on households’ ability and willingness to join the community-based health insurance (CBHI) scheme in Ethiopia is inadequate and lacks representativeness and disaggregation. Thus, the aim of this study was to assess the ability to pay (ATP) and willingness to pay (WTP) for CBHI membership and to identify factors that WTP Methods A nationwide cross-sectional household survey, involving both CBHI member and nonmember households, was conducted from February to May 2020. Two-stage stratified cluster sampling was used to select enumeration areas (EAs) and households from within EAs. ATP was measured using the spending net of the poverty line approach. The maximum monetary value that obtained a “yes” response in the bidding game exercise was used as a measure of WTP. Linear regression analysis was used to identify the factors associated with WTP. Results Among the study participants, 30.9% were active members of the scheme. The mean ATP was Ethiopian Birr (ETB) 3,992.45 (USD 139.4) at 10% and ETB 15,969.82 (USD 557.6) at 40% cutoff. The mean WTP was ETB 244 (SD = ETB 175.4) in rural areas and ETB 361.6 (SD = ETB 210.8) in urban areas per household per year. The average WTP was higher if the family size was increased by one person both in rural (AMD = 9.3; 95% CI [6.8, 11.9]) and urban (AMD = 7.2; 95% CI [1.0, 13.4]) settings and positively associated with ATP for CBHI (AMD = 64.1; 95% CI [6.3, 121.8]) in urban settings. The male and literate respondents in urban areas had higher mean WTP values (AMD = 39.8; 95% CI [13.1, 66.4] and AMD = 56.8; 95% CI [26.1, 87.4], respectively) compared to their counterparts. Being a leader in the Health Development Army (HDA), Women’s Development Army (WDA), or a 1:5 network (in urban settings) positively affected WTP (AMD = 23.4; 95% CI [3.4, 43.5]). Conclusions Most households could afford the CBHI premiums at a 10% threshold. Premium revisions based on ATP, while addressing challenges in WTP through an in-depth understanding of modifiable factors and by adopting effective strategies to modify these factors, is crucial.