The Introduction of Social Health Insurance and Health Care Seeking Behavior in Urban Ethiopia

Objectives: In recent years, to enhance access to and use of health care the government of Ethiopia has introduced voluntary Community Based Health Insurance (CBHI) schemes for the rural and informal sectors of the economy. After years of planning and the ratification of a legal framework the government proposes to introduce a compulsory Social Health Insurance (SHI) program for formal sector employees. The proposed scheme will provide access to contracted health care facilities at a premium of 3% of the gross monthly income of employees with another 3% coming from the employer. While several studies have examined the willingness to pay this premium, little is known about the health care seeking behaviour (HSB) of formal sector employees. In part, the implementation of the SHI has been delayed due to the unwillingness of public servants to pay the proposed premium. Scheme coverage which will be restricted to contracted facilities, may also be contentious if this is dominated by publicly provided health care services. This paper investigates both, the determinants of health care seeking behaviour of formal sector employees and their families and attitudes related to the introduction of SHI such as fairness, affordability, and willingness to pay the SHI premium. Through these explorations, the paper sheds light on the potential challenges for the implementation of SHI. Setting: The study is based on a survey of formal sector employees and their families in urban Ethiopia. It covers the major administrative regions of the country and contains information on 2,749 formal sector employees and their families or a total of 6,894 individuals. Results: Regarding outpatient care, conditional on falling ill, 85.5% sought some form of care within a couple of days (2.4 days) of falling ill. The bulk (94%) of those who did seek care, opted for formal treatment. A majority of the visits (55.9%) were to private health clinics or hospitals. In the case of inpatient care, the picture was reversed with a majority of health care seekers visiting public sector hospitals (62.5%). There is a strong positive link between income and the use of private health services. A majority of the sample (67%) supported the introduction of SHI but only about 24% were willing to pay a premium of 3% of their gross monthly income. The average WTP was 1.6%. Respondents in the two richest income quintiles were far more likely to oppose SHI and consider it unfair. Conclusion: The prominent role of the private sector especially in terms of outpatient care and the stronger resistance to SHI amongst the two richest income quintiles, that is, those who are most likely to use private health care providers, suggests that the SHI program needs to actively include private health care facilities within its ambit. Additionally, as was done prior to the introduction of the CBHI, concerted efforts at enhancing the quality of care available at public health facilities, both, in terms of perception and patient-centred care and in terms of addressing drug and equipment availability bottlenecks, are needed. A combination of these two measures is likely to enhance support for the introduction of SHI.