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

Background . is of the countries with high out-of-pocket to The of 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 imple-mentation 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.


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][7][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][22][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. erefore, this study aimed to assess the acceptance of SHI and its associated factors among health professionals in government hospitals, Mekelle city, Ethiopia.

Study Design and
Setting. An institution-based crosssectional study design was used to assess acceptance for social health insurance and its associated factors among health professionals in Mekelle city.
e 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.

Study Population and Sampling Procedures.
e source population of this study was all health professionals in the government hospitals in Mekelle city. e 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. e 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. ree government hospitals in the study area were included in the study, and a list of the health professionals was obtained from the three hospitals. e 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.

Study Variables
e 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? e 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. e 3% premium was set by the government of Ethiopia to implement the SHI [31].

Explanatory Variables.
e 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.

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].

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). ose who had a mean score greater than 3 were considered as having a positive/favorable attitude otherwise negative/unfavorable [32].

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

Data Collection Procedures.
A structured intervieweradministered 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. e 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. e 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. en, in the final data collection, the study participants assisted by the data collectors filled in the questionnaire. e collected data were checked by the data collectors' supervisors as well as the principal investigator.

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 highwealth status. Initially, bivariable logistic regression at a p value of less than 0.25 was used to identify factors independently associated with the outcome variable. en 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.

Demographic and Socioeconomic Characteristics of the Respondents.
A total of 408 health professionals participated in the study with a response rate of 97%. e 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%). e mean age of respondents was 32 ± 6.7 years (Table 1).

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 ( Figure 1).

Awareness, Knowledge, and Attitudes about Social Health
Insurance.
e 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.
e 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.

Acceptance of Social Health Insurance.
e 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. e median (IQR) of maximum willingness to pay was 3% [1] of monthly salary ( Table 2). e 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).

Factors Associated with Acceptance of Social Health
Insurance.
e 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. e 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 Advances in Public Health  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 (Table 3).

Discussion
is 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. is 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. e 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. is disparity could be due to the difference in the burden of medical bills when seeking health care services [34].
e 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]. is could be due to the socioeconomic differences among countries. e results of this study showed that respondents with high monthly salaries were more likely to be willing to pay for SHI. is could be due to their ability to afford health insurance premiums and contribution for SHI being progressive is good. is 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. is 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.
is 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. is finding is consistent with findings from Ebonyi State, Nigeria [40] and Central Vietnam [12]. is 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. is is consistent with the finding of a study conducted in southwestern Nigeria [34]. is study revealed that perception about the quality of health care services if SHI implemented was positively associated with acceptance of SHI. is is similar to the result of research done in Debre Markos [19]. e 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.
is 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. is 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.

Limitations of the study
is 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.

Conclusion
e 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. erefore, 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. Data Availability e datasets supporting the conclusions of this article are available upon request to the corresponding author. Due to data protection restrictions and participant confidentiality, participants' data are not publicly available.

Ethical Approval
Ethical approval was obtained from University of Gondar Institutional Review Board and Permission letter was secured from Tigray Health Bureau and respective health institutions.

Consent
Written consent from study participants were obtained after explaining the purpose of the study and confidentiality was assured for the information provided by using the coding system; questionnaires did not have any personal identifiers and respondents were informed data are used for study purpose only. Confidentiality and anonymity were ensured. Study participants were informed that participation had no impact on the provision of their health care. All forms and data related to the study were stored in a locked room in a secured area, with controlled access available only to the investigators. Participation in the study was voluntary and individuals were free to withdraw or stop the interview at any time.

Disclosure
is study is part of a master thesis funded by the University of Gondar.
e preliminary findings of this study were presented at Institute of Public Health, University of Gondar. e funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Conflicts of Interest
e authors declare that they have no conflicts of interest.

Authors' Contributions
AT designed the study, developed data collection tools, performed the analysis and interpretation of data, and drafted the paper. MY and AK participated in the development of the study proposal, analysis and interpretation, revised drafts of the paper, and revised the manuscript. All authors read and approved the final manuscript.
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