Background: More than 4 billion people worldwide still lack social protection. However, the policy provides a framework for collaboration and coordination within the social protection system, aiming to deliver various services through an organized structure at all levels. Therefore, the aim of this study was to assess willingness to pay for social health insurance and its associated factors among public servants in Lideta Sub-city; Addis Ababa, Ethiopia. Methods: An institutional-based cross-sectional study was conducted from September 15 to November15/2023 using systematic random sampling among 381 permanent public servants in Lideta sub-city of Addis Ababa Ethiopia. Participants were interviewed using a structured pretested closed questionnaire to obtain detail data from respondents for different variables. The data was entered into the Kobo toolbox and exported to SPSS version 26.00 for analysis. Descriptive analysis and cross tabulation was done to see the picture of the data. Bivariate and multivariate logistic regression analysis was done at 95% of confidence interval. Those variables with P-value less than 0.05 along with their Adjusted Odds Ratio (AOR) were declared as a predictor of the outcome variables in the study. Results: A total of 381 government employees completed the questionnaire with a response rate of 100 %. Overall, 64.3% of respondents were willing to pay the proposed premium (3% of their monthly salary). Public servant who knew social health insurance scheme [AOR= 2.24, (95% CI: 1.31, 3.82)], those have good knowledge [AOR= 4.23, (95% CI: 2.15, 8.32)], those had a history of chronic disease [AOR= 2.46, (95% CI: 1.16, 5.21)] were associated with willingness to pay for social health insurance. Conclusions: The willingness to pay 3% of the monthly gross salary for social health insurance was 64.3 %. Public servant who knew social health insurance, having good knowledge and history of previous chronic diseases are identified as predictors of willingness to pay for social health insurance. Thus, the government of Ethiopia and Addis Ababa city administration recommended starting social health insurance. In addition qualitative study will be further recommended to get the detail investigation.
This is an Open Access article, distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium or format, provided the original work is properly cited.
Social Health Insurance, Public Sectors, Willingness to Pay, Lideta Sub-city, Addis Ababa, Ethiopia
1. Background
In the world more than 4billion people still lack social protection including Social Health Insurance (SHI), which is used for raising and pooling funds to finance and manage health services that will lead to Universal Health Coverage (UHC) and assist countries achieve their health systems objectively
[1]
Assefa Y, Hill PS, Gilks CF, Admassu M, Tesfaye D, Van Damme W. Primary health care contributions to universal health coverage, Ethiopia. Bulletin of the World Health Organization. 2020; 98(12): 894. Available from:
The key functions of the health financing system framework designed by the World Health Organization (WHO) include revenue generation, pooling, and purchasing of health services. This can be achieved through various means such as creating an insurance system, tax financing, private health insurance, and community-based health insurance (CBHI). These pooled funds will support public health by combining the health risks and contributions of employees. It is essential to focus on these healthcare financing mechanisms to achieve Universal Health Coverage in the country
[3]
Rawlings DA. Building social protection and labor systems: concepts and operational implications [Internet]. Social Protection Discussion Papers and Notes. The World Bank; 2012. Available from:
Organization WH. Report of the second WHO consultation on the global action plan for influenza vaccines (GAP), Geneva, Switzerland, 12-14 July 2011. 2012. Available from:
Doetinchem O, Carrin G, Evans D. Thinking of introducing social health insurance? Ten questions Technical brief for policy-makers, Number 4/2009 World Health Organization. Available from:
Marine Le Gall-Ely. Definition, Measurement and Determinants of the Consumer’s Willingness to Pay: a Critical Synthesis and Directions for Further Research. Recherche et Applications en Marketing (French Edition), 2009, 24(2), pp. 91-113. hal-00522828. Available from:
Health care insurance and financing represent a significant gap in sub-Saharan African countries. Ethiopia is among these nations that initiated health care financing strategies with its health policy launched in 1993. Health insurance was emphasized as a key component of the health care financing strategy (HCFS) in 1998, and it was further highlighted in the revised national health strategy in 2017
[7]
Ewunetie Mekashaw Bayked, Husien Nurahmed Toleha, Beletu Berihun Chekole, Birhanu Demeke Workneh, Mesfin Haile Kahissay. Willingness to pay for social health insurance in Ethiopia: A systematic review and meta-analysis. Frontiers in Public Health. 2023 Mar 22; 11. Available From:
Developed countries often utilize Social Health Insurance (SHI) to mobilize funds and pool risks, while low- and middle-income countries rarely adopt this approach. In Ethiopia, there is a strategic healthcare financing system that has been established recently; however, it has not yet been effectively implemented. Currently, only 38% of the eligible population has joined the community health insurance program. Legal frameworks have been developed, and many preparatory activities have taken place to implement the Social Health Insurance Scheme, which requires government employees to contribute 3% of their gross salary
[8]
Abdene Weya Kaso, Girma Worku Obsie, Berhanu Gidisa Debela, Abdurehman Kalu Tololu, Mohammed E, Habtamu Endashaw Hareru, et al. Willingness to pay for Social Health Insurance and associated factors among Public Civil Servants in Ethiopia: A systematic review and meta-analysis. PLoS ONE. 2024 Feb 9; 19(2): e0293513–3. Available from:
World Health Organization. Country Office for Ethiopia. The work of WHO in Ethiopia during 2017. World Health Organization. Country Office for Ethiopia. 2018.
One major reason for the repeated postponement of the SHI scheme's implementation in Ethiopia is the resistance from public servants to pay the proposed premium amount. Although there is no national study on the willingness to pay (WTP) for SHI in Ethiopia, several localized studies have been conducted, focusing on specific groups of public servants. These studies have produced generalized findings indicating public servants' willingness to contribute to Social Health Insurance
[8]
Abdene Weya Kaso, Girma Worku Obsie, Berhanu Gidisa Debela, Abdurehman Kalu Tololu, Mohammed E, Habtamu Endashaw Hareru, et al. Willingness to pay for Social Health Insurance and associated factors among Public Civil Servants in Ethiopia: A systematic review and meta-analysis. PLoS ONE. 2024 Feb 9; 19(2): e0293513–3. Available from:
World Health Organization. Country Office for Ethiopia. The work of WHO in Ethiopia during 2017. World Health Organization. Country Office for Ethiopia. 2018.
Kidane M. Assessment on the challenges of social health insurance implementation in Akaki Kaliti Subcity administration from public servants perspective: St. Mary's University; 2020. Available from:
. Therefore, the aim of this particular study was to assess the willingness to pay for social health insurance and its associated factors among public servants in Lideta Sub city of Addis Ababa, Ethiopia.
2. Methods and Materials
2.1. Study Setting
The current study was conducted in the Lideta Sub-city of Addis Ababa, Ethiopia. Addis Ababa serves as the capital city of Ethiopia, with a population of approximately 4.8 million residents. The city is divided into 11 sub-cities and 118 woredas, which is the smallest administrative unit in the city. According to the 2019 administrative report, there are 115,398 public servants in Addis Ababa who provide various public services. Within the Lideta Sub-city, there are 9,361 public servants dedicated to serving the community. Lideta Sub-city consists of ten woredas and has a total population of 356,802. It is bordered by Addis Ketema Sub-city to the North, Arada Sub-city to the North-East, Kirkos Sub-city to the East, Nifas Silk Lafto Sub-city to the South, and Kolfe Keranio Sub-city to the West
[11]
Addis Ababa City Administration, Lideta Sub City Administration Annual Performance Report, 2022. Addis Ababa, Ethiopia. Unpublished.
Figure 1. Map Lideta Sub-city, Addis Ababa, Ethiopia (Map of the Study Area, Arc GIS, 2023).
2.2. Study Design, Sample Size Determination and Sampling Procedure
An institutional-based cross-sectional study design was conducted from September 15 to November 15, 2023. The source population for the study included all public servants in Lideta sub-city, while the study population comprised the public servants selected and included during the study period. Employees in Lideta sub-city who were on annual leave or had been employed for less than six months were excluded from the study. The sample size for this study was calculated using a single population proportion formula, based on the assumption that 53% of public servants in South Ethiopia are willing to use social health insurance
[12]
Haile LM, Sinkie, Shimeles Ololo, Megerssa B. Willingness to Pay for Community-Based Health Insurance among Rural Households of Southwest Ethiopia [Internet]. arXiv.org. 2019 cited 2025 Jan 10]. Available from:
. With a margin of error set at 5% and a confidence interval of 95% (Z = 1.96), alongside a 10% non-response rate, the initial sample size (n) was calculated to be 421 using the formula n= (Z α/2) 2 * p * (1-p)/ d2.
However, since the total population of public servants in the Lideta Sub-city is less than 10,000, a population correction formula was applied. Using the adjustment formula n=no/1+ no/N, the maximum sample size for the study was revised to 381.
The systematic random sampling method was employed using a Kth interval to select the desired subjects. The list of respondents was obtained from data collected and registered one year prior to the study period. The K-interval was calculated by dividing the total number of public servants for the first month, which was 3,067, by the sample size (3,067 / 381 = 8). Initially, the first public servant was selected using a lottery method. Subsequently, every eighth public servant who qualified for selection was included in the study (Figure 2).
2.3. Data Collection Procedures and Quality Control
Data was collected using a structured interview questionnaire, which was first translated from English to Amharic and then back to English to ensure consistency. To guarantee the quality of the data, a well-designed data collection instrument was pre-tested on 5% of the total sample size in the Kolfe Keranio Sub-city of Addis Ababa, Ethiopia. The research instrument underwent testing for internal consistency using the Cronbach alpha coefficient (α = 0.74). The instrument was pre-coded, and necessary corrections were made before finalizing it. Based on the findings from the pretest, several modifications and amendments were implemented before actual data collection began.
Five data collectors (diploma holders) and two supervisors (bachelor’s degree holders), were trained for one day by the principal investigator. This training aimed to familiarize them with the research objectives and methodology, ensuring that their interviewing techniques were standardized and questions were asked consistently. During the data collection process in the field, questionnaires were reviewed at the end of each day for completeness, accuracy, and consistency by the principal investigator, who also implemented corrective measures as necessary.
2.4. Operational Definitions
Public Institution: A public institution is an established organization owned and operated by the government or a public entity. This research focuses on public servants in all government institutions that are registered and directly accountable to the Lideta sub-city administration
[12]
Haile LM, Sinkie, Shimeles Ololo, Megerssa B. Willingness to Pay for Community-Based Health Insurance among Rural Households of Southwest Ethiopia [Internet]. arXiv.org. 2019 cited 2025 Jan 10]. Available from:
Health status of the participants: Health status refers to how individuals perceive their own health, rating it as excellent, very good, good, fair, or poor. In this research, a "good health status" is defined as a situation where the participant or their family members have become ill and visited a health facility at least once in the past six months. Conversely, "excellent health status" is determined when the participant or their family has been ill and sought care at a health facility at least once in the past year, or has remained healthy over the past year without any visits to a health facility
[2]
World Health Organization. Tracking Universal Health Coverage: 2023 Global monitoring report [Internet]. Available from:
Kokebie, M. A., Abdo, Z. A., Mohamed, S. et al. Willingness to pay for social health insurance and its associated factors among public servants in Addis Ababa, Ethiopia: a cross-sectional study. BMC Health Serv Res 22, 909 (2022).
Mekuria M, Girma T. Community-based health insurance coverage: Drop-out rates and associated factors among households in selected districts of West Shewa Zone, Ethiopia. 2020. Available From:
Willingness to pay: Willingness to pay (WTP) refers to the maximum amount that a customer is prepared to pay for a product or service. In this study, WTP specifically pertains to the intention to enroll and pay for Social Health Insurance. A respondent is considered willing to pay for Social Health Insurance if they answer "yes" to both questions assessing their need and readiness to pay, and also indicate a willingness to dedicate at least 3% of their salary towards the Social Health Insurance premium
[13]
Kokebie, M. A., Abdo, Z. A., Mohamed, S. et al. Willingness to pay for social health insurance and its associated factors among public servants in Addis Ababa, Ethiopia: a cross-sectional study. BMC Health Serv Res 22, 909 (2022).
Mekuria M, Girma T. Community-based health insurance coverage: Drop-out rates and associated factors among households in selected districts of West Shewa Zone, Ethiopia. 2020. Available From:
The data were entered, edited, and coded using the Kobo Toolbox. Data export was performed for further analysis with SPSS software version 26.00. Descriptive statistics analysis including frequencies, percentages, means, and standard deviation was conducted to illustrate the distribution of the data, with results presented in tables and figures. Bivariate analysis was carried out for each independent variable determined the dependent variable. Variables with a p-value of less than 0.25 were selected through a stepwise elimination method and included in the multivariable analysis to evaluate the willingness to pay for social health insurance alongside various explanatory variables.
To check for multi-collinearity among the explanatory variables, correlation matrices, variance inflation factor (VIF > 10), and tolerance tests were utilized. A multiple logistic regression model was fitted to the data. The strength of the statistical association between the dependent and independent variables was assessed using a p-value of less than 0.05 and an adjusted odds ratio (AOR) within a 95% confidence interval. The results from the multiple logistic regression models were considered significant at p < 0.05.
2.6. Ethical Clearance
The research proposal was approved by the Research Ethical Review Committee of the Africa Medical College Department of Public Health. A permission letter was obtained from the Addis Ababa City Administration Health Bureau Research Ethics Review Board. All procedures were conducted with human participants, and verbal informed consent was obtained from each participant. Participants were informed as they had the right to refuse participation at any time. To ensure confidentiality, each participant’s information was protected by assigning identification numbers to the questionnaires and removing names and other identifying details during the interviews. The findings of the study were shared with the management bodies of the Lideta Sub-City Administration and the Department of Public Health at Africa Medical College.
3. Results
The present study was carried out on 381 (100%) respondents using systematic random sampling technique. The magnitude of participants’ willing to pay a premium equivalent three percent for social health insurance was reported as 64.3%. The mean age of the participants were 38 years +/-4SD with a minimum and maximum of age 24 and 62 respectively.
3.1. Socio Demographic Characteristics
In the current study most of the respondents in the study who were willing to pay for social health insurance were married, totalling 244 participants (64.1%). This was followed by 119 single respondents (31.2%). Concerning monthly income and family size, 148 respondents (38.8%) earned a monthly income between 7,801 and 10900 ETB was willing to pay SHI. Additionally, 171 respondents (44.9%) had family sizes ranging from 4 to 6 members per household who were willing to pay the social health insurance premium (see Table 1).
Table 1. Respondents Socio Demographic Characteristics for Willingness to pay for SHI (n= 381).
Sr.No
Variables
Category
Frequency (No)
Percent (%)
1
Sex
Male
178
46.7%
Female
203
53.3%
2
Age in Years
20 – 30
116
30.4%
31 – 40
182
47.8%
41 – 50
62
16.3%
>/= 51
21
5.5%
3
Marital status
Single
119
31.2%
Married
244
64.1%
Widowed
7
1.8%
Divorced
11
2.9%
4
House Holds Family Size
< / = 3
200
52.5%
4 – 6
171
44.9%
>/= 8
10
2.6%
5
Respondents Educational Status
Secondary School
3
0.8%
Diploma
79
20.7%
Degree
238
62.5%
Masters and above
61
16.0%
6
Respondents Profession
Health Professionals
157
41.2%
None Health Professionals
224
58.8%
7
Respondents Monthly Income
ETB 601-1650
4
1.0%
ETB 1651-3200
1
0.3%
ETB 3201-5250
61
16.0%
ETB 5251- 7800
143
37.5%
7801-10900
148
38.8%
>/=10901
24
6.3%
3.2. Individual Related Characteristics
In terms of information sources regarding social health insurance, the majority of public servants, 132 (35%), obtained information from health professionals during their visits to health facilities. This was followed by 72 (19%) who received information from official advertisements via media platforms (Figure 3).
Figure 3. Source of information about Social Health Insurance (n=381).
3.3. Health and Health Related Factors (Characteristics)
In a particular study, researchers assessed health-related factors influencing willingness to pay for social health insurance premiums. Among the respondents, 166 individuals (43.6%) who rated both their own and their family's health as good expressed a willingness to pay the premiums. Additionally, 297 participants (78.0%) who found their health facilities easily accessible were also willing to pay. However, 104 participants (74.8%) disagreed with the statement that their monthly income was insufficient to cover the cost of social health insurance (see Table 2).
Table 2. Health and Health Related Factors on willingness to pay for SHI (n = 381).
Sr.No
Variable
Category
Frequency (no)
Percent (%)
1
Self and family health status
Excellent
110
28.8%
Very good
105
27.6%
Good
166
43.6%
2
Health facility physically accessible
Yes
297
78.0%
No
84
22.0%
3
Health facility service
Yes
313
82.2%
No
68
17.8%
4
Suffering chronic illness
Yes
63
16.5%
No
318
83.5%
5
Illness in the past 3 months
Yes
184
48.3%
No
197
57.7%
6
Willing to cover social health insurance
Yes
344
90.3%
No
37
9.7%
7
Willingness to pay 3 percent of your gross salary for Social Health Insurance
Yes
245
64.3%
No
136
35.7%
8
Explained Reasons not willing due to services provided
Poor service delivery
7
5%
Bureaucratic
6
4%
Insufficient drug supply
24
18%
Low monthly income
101
51%
Others
35
21%
3.4. Factors Affecting the Willingness to Pay for Social Health Insurance
The study examined the factors influencing the willingness to pay for social health insurance among public servants in the Lideta sub-city of Addis Ababa, Ethiopia. Key factors tested included age, educational status, experiences with chronic illness, illness within the three months leading up to the study, self and family health status, knowledge of social health service coverage schemes, and other relevant variables. A stepwise enter method was employed in the bivariate analysis. Variables with a p-value of less than 0.25 were identified as potential candidates for multivariate analysis based on their clinical significance. Potential confounders were adjusted, and the model's goodness of fit was evaluated using the Hosmer-Lemeshow test (X² = 6.56; df = 8; P = 0.388).
According to the results, the odds of willingness to pay for Social Health Insurance were two times higher among those who suffer from chronic illness than those who don’t [(AOR= 2.43, (95% CI: 1.16, 5.21)], and it is statistically significant at p-value = 0.019. Moreover, public servants whose family health status is very good were four times more likely willing to pay for Social Health Insurance than those whose family health status is good [(AOR =4.23, (95% CI: 2.15, 8.32) ] which is statistically significant at P-value < 0.001 (Table 3).
Table 3. Factors Associated with willingness to pay for Social Health Insurance.
Sr.No
Variables
WTP for SHI
COR (95% CI)
AOR (95% CI)
P-value of AOR
Yes (%)
No (%)
1
Sex
Male
115(30.2)
59(15.5)
1.15(0.56, 1.76)
0.82(0.51, 1.33)
0.423
Female
130(34.1)
77 (20.2)
1.00
1.00
2
Age category
</= 40 years
99(26.0)
67(17.6)
1
1
> 40 years
146(38.6)
69(18.1)
1.43(0.94, 2.18)
1.31(0.82, 2.11)
0.261
3
Educational status
Diploma
40(10.5)
39(10.2)
1
1
Degree
162(42.5)
78(20.5)
2.03(1.21, 3.40)
1.29(0.71, 2.37 )
0.406
>/=Masters
43(11.3)
19(5.0)
2.21(1.10, 4.43 )
1.54(0.69, 3.40)
0.290
4
Suffering from chronic illness
Yes
53(13.9)
10(2.6)
3.48(1.71, 7.09)
2.46(1.16, 5.21)
0.019 *
No
192(50.4)
126(33.1)
1
1
192(50.4)
5
Illness in the past 3 months
Yes
135(35.4)
48(12.6)
2.25(1.46, 3.47)
1.82(1.13, 2.94)
0.014 *
No
110(28.9)
88(23.1)
1
1
110(28.9)
6
Self and Family Health Status
Excellent
54(14.2)
56(14.7)
0.59(0.36, 0.91)
1.30(0.77, 2.21)
0.327
Very Good
88(23.1)
17(4.7)
3.17(1.73, 5.81)
4.23(2.15, 8.32)
< 0.001
Good
103(27.0)
63(16.5)
1
1
7
Knowing Health service coverage under SHI scheme
Yes
190(49.9)
77(20.2)
2.65(1.68, 4.16)
2.24(1.31, 3.82)
0.003
No
55(15.5)
59(14.4)
1
1
*significant at P-value less than 0.05
** Significant at P value less than 0.001
4. Discussion
In the current study the magnitude of willingness to pay for social health insurance premium from three percent from their monthly salary was 64.3%. This indicated that nearly two third of respondents reported their willingness to pay. This finding is aligned and consistent with the study conducted in South West Ethiopia, which as 58.0% and other part of the country
[15]
Mekonne A, Seifu B, Hailu C, Atomsa A. Willingness to pay for social health insurance and associated factors among health care providers in Addis Ababa, Ethiopia. Bio Med research international. 2020.
Mulat, A. K., Mao, W., Bharali, I. et al. Scaling up community-based health insurance in Ethiopia: a qualitative study of the benefits and challenges. BMC Health Serv Res 22, 473 (2022).
Chiwire P, Evers SM, Mahomed H, Hiligsmann M. Willingness to pay for primary health care at public facilities in the Western Cape Province, Cape Town, South Africa. J Med Econ. 2021 Jan-Dec; 24(1): 162-172.
. This similarity might be explained by similarity of the study setting and interests of public servants for social health insurance in Ethiopia. However, this study finding is lower than the study conducted in Mekelle city, Ethiopia which was 85.3% (18). Moreover, the study finding is higher than the study conducted in Ethiopia which was 42.3%, in Addis Ababa 28.7% & 35.4%, and in Mujja town 42.3%
[14]
Mekuria M, Girma T. Community-based health insurance coverage: Drop-out rates and associated factors among households in selected districts of West Shewa Zone, Ethiopia. 2020. Available From:
Mulat, A. K., Mao, W., Bharali, I. et al. Scaling up community-based health insurance in Ethiopia: a qualitative study of the benefits and challenges. BMC Health Serv Res 22, 473 (2022).
Bayked EM, Toleha HN, Chekole BB, Workneh BD, Kahissay MH. Willingness to pay for social health insurance in Ethiopia: A systematic review and meta-analysis. Front Public Health. 2023 Mar 22; 11: 1089019.
Gidey MT, Gebretekle GB, Hogan M-E, Fenta TG. Willingness to pay for social health insurance and its determinants among public servants in Mekelle City, Northern Ethiopia: a mixed methods study. Cost Effectiveness and Resource Allocation. 2019; 17: 1-11. Available From:
Regassa Z, Negera E, Silashi T, Kaba Z, Mosisa G. Willingness to join and pay social health insurance and associated factors among public sectors workers in Didu Woreda, South West Ethiopia, 2018. J Public Health Res. 2022 Sep 28; 11(3): 22799036221123957.
. This difference might be due to difference in study setting, exposure to primary health care unit. Overall, the possible explanation for this difference might be due to differences in study period, study area, study population, and also socio-demographic factors.
According to the results, the odds of willingness to pay for Social Health Insurance were two times more likely among those who suffer from chronic illness than those who did not. This finding was supported by a study conducted in Addis Ababa
[16]
Mulat, A. K., Mao, W., Bharali, I. et al. Scaling up community-based health insurance in Ethiopia: a qualitative study of the benefits and challenges. BMC Health Serv Res 22, 473 (2022).
Tahir, A., Abdilahi, A. O. & Farah, A. E. Pooled coverage of community based health insurance scheme enrolment in Ethiopia, systematic review and meta-analysis, 2016–2020. Health Econ Rev 12, 38 (2022).
Bayked EM, Toleha HN, Chekole BB, Workneh BD, Kahissay MH. Willingness to pay for social health insurance in Ethiopia: A systematic review and meta-analysis. Front Public Health. 2023 Mar 22; 11: 1089019.
Chiwire P, Evers SM, Mahomed H, Hiligsmann M. Willingness to pay for primary health care at public facilities in the Western Cape Province, Cape Town, South Africa. J Med Econ. 2021 Jan-Dec; 24(1): 162-172.
Regassa Z, Negera E, Silashi T, Kaba Z, Mosisa G. Willingness to join and pay social health insurance and associated factors among public sectors workers in Didu Woreda, South West Ethiopia, 2018. J Public Health Res. 2022 Sep 28; 11(3): 22799036221123957.
Mekonnen Degie F, Agumas Ambelie Y, Mulu Gelaw Y, Fentaw Mulaw G, Wassie Feleke F. Willingness to pay for social health insurance and its predictors among government employees in Mujja Town, Ethiopia. The Scientific World Journal. 2021; 2021: 1-7. Available From:
Batbold, O., Pu, C. Willingness to pay for private health insurance among workers with mandatory social health insurance in Mongolia. Int J Equity Health 20, 7 (2021).
. This might be due to the fact that public servants with chronic illnesses might have difficulty living with current inflation and such high health costs. Therefore, it is obvious that those with chronic illnesses need intensive follow-up, and there are different expenditures for laboratory and medicine services. Chronic illness was associated with a willingness to pay for social health insurance.
This study showed that family health status was associated with the willingness to pay for Social Health Insurance. Public servants whose family health status was very good were 4 times more willing to pay for Social Health Insurance than those whose family health status was good. This finding was supported by a study conducted in Western Cape Province and South Africa which is explained as 60%
[19]
Gidey MT, Gebretekle GB, Hogan M-E, Fenta TG. Willingness to pay for social health insurance and its determinants among public servants in Mekelle City, Northern Ethiopia: a mixed methods study. Cost Effectiveness and Resource Allocation. 2019; 17: 1-11. Available From:
This study also revealed that, recent infections in the last three months were associated with a willingness to pay for Social Health Insurance. The odds of willingness to pay for Social Health Insurance were two times higher among public servants who got infections in the last three months than those who were not infected. This finding was supported by a study conducted in Ethiopia
[14]
Mekuria M, Girma T. Community-based health insurance coverage: Drop-out rates and associated factors among households in selected districts of West Shewa Zone, Ethiopia. 2020. Available From:
Mulat, A. K., Mao, W., Bharali, I. et al. Scaling up community-based health insurance in Ethiopia: a qualitative study of the benefits and challenges. BMC Health Serv Res 22, 473 (2022).
Bayked EM, Toleha HN, Chekole BB, Workneh BD, Kahissay MH. Willingness to pay for social health insurance in Ethiopia: A systematic review and meta-analysis. Front Public Health. 2023 Mar 22; 11: 1089019.
Chiwire P, Evers SM, Mahomed H, Hiligsmann M. Willingness to pay for primary health care at public facilities in the Western Cape Province, Cape Town, South Africa. J Med Econ. 2021 Jan-Dec; 24(1): 162-172.
. This similarity might be explained by the fact that those parents who infect in the near future knew the cost of laboratory and medicine, and in order to cover this high cost, they were willing to pay for Social Health Insurance.
Knowing health service coverage under the Social Health Insurance scheme was associated with willingness to pay for Social Health Insurance. The odds of willingness to pay for Social Health Insurance were two times higher among public servants who knew about health service coverage under the Social Health Insurance scheme than those who did not. This study is also supported by study conducted in Ethiopia
[14]
Mekuria M, Girma T. Community-based health insurance coverage: Drop-out rates and associated factors among households in selected districts of West Shewa Zone, Ethiopia. 2020. Available From:
Mekonne A, Seifu B, Hailu C, Atomsa A. Willingness to pay for social health insurance and associated factors among health care providers in Addis Ababa, Ethiopia. Bio Med research international. 2020.
Bayked EM, Toleha HN, Chekole BB, Workneh BD, Kahissay MH. Willingness to pay for social health insurance in Ethiopia: A systematic review and meta-analysis. Front Public Health. 2023 Mar 22; 11: 1089019.
Regassa Z, Negera E, Silashi T, Kaba Z, Mosisa G. Willingness to join and pay social health insurance and associated factors among public sectors workers in Didu Woreda, South West Ethiopia, 2018. J Public Health Res. 2022 Sep 28; 11(3): 22799036221123957.
. This might be due to the fact that those who knew the services provided under the scheme were easily willing to pay for social health insurance.
One of the limitations of the present study was the limited number of studies conducted on the study setting leading to the restriction of further discussion and comparison. Due to the cross-sectional design of the study, it was difficult to show the cause-effect relationship between the outcomes and predictor variables which might allow for the possibility of optimistic fallacy and external validity.
Regardless of the aforementioned limitations the findings of this study provide the decision makers in the study setting with appropriate interventions for the promotion of women’s decision-making.
5. Conclusions
In the current study, the willingness of public servants to pay for social health insurance was found to be high, at 64.3%. Respondents who reported very good health status within their family, had experienced illness in the past three months, were aware of the health services covered under social health insurance, and were suffering from chronic illnesses showed a significant association with their willingness to pay for the insurance. Therefore, it is essential for government bodies and stakeholders, including the Addis Ababa city administration and all sub-cities in Addis Ababa, to implement social health insurance as a key health policy. Furthermore, it is recommended that researchers conduct additional studies, including qualitative research, to gain deeper insights.
Abbreviations
SHI
Social Health Insurance
UHC
Universal Health Coverage
WHO
World Health Organization
AOR
Adjusted Odds Ratio
COR
Cruds Odds Ratio
ETB
Ethiopian Birr
CBHI
Community Based Health Insurance
CI
Confidence Interval
Acknowledgments
The authors would like to thank the study participants, data collectors, supervisors, and all other individuals cooperating in any stages of this study.
Authors Contributions
Getachew Jufare: Conceptualization, Data curation, Formal Analysis, Investigation, Methodology, Writing – original draft
Lakech Haile: Data curation, Formal Analysis, Software
Funding
This work is not supported by any external funding.
Conflicts of Interest
The authors declare no conflicts of interest.
References
[1]
Assefa Y, Hill PS, Gilks CF, Admassu M, Tesfaye D, Van Damme W. Primary health care contributions to universal health coverage, Ethiopia. Bulletin of the World Health Organization. 2020; 98(12): 894. Available from:
Rawlings DA. Building social protection and labor systems: concepts and operational implications [Internet]. Social Protection Discussion Papers and Notes. The World Bank; 2012. Available from:
Organization WH. Report of the second WHO consultation on the global action plan for influenza vaccines (GAP), Geneva, Switzerland, 12-14 July 2011. 2012. Available from:
Doetinchem O, Carrin G, Evans D. Thinking of introducing social health insurance? Ten questions Technical brief for policy-makers, Number 4/2009 World Health Organization. Available from:
Marine Le Gall-Ely. Definition, Measurement and Determinants of the Consumer’s Willingness to Pay: a Critical Synthesis and Directions for Further Research. Recherche et Applications en Marketing (French Edition), 2009, 24(2), pp. 91-113. hal-00522828. Available from:
Ewunetie Mekashaw Bayked, Husien Nurahmed Toleha, Beletu Berihun Chekole, Birhanu Demeke Workneh, Mesfin Haile Kahissay. Willingness to pay for social health insurance in Ethiopia: A systematic review and meta-analysis. Frontiers in Public Health. 2023 Mar 22; 11. Available From:
Abdene Weya Kaso, Girma Worku Obsie, Berhanu Gidisa Debela, Abdurehman Kalu Tololu, Mohammed E, Habtamu Endashaw Hareru, et al. Willingness to pay for Social Health Insurance and associated factors among Public Civil Servants in Ethiopia: A systematic review and meta-analysis. PLoS ONE. 2024 Feb 9; 19(2): e0293513–3. Available from:
World Health Organization. Country Office for Ethiopia. The work of WHO in Ethiopia during 2017. World Health Organization. Country Office for Ethiopia. 2018.
Kidane M. Assessment on the challenges of social health insurance implementation in Akaki Kaliti Subcity administration from public servants perspective: St. Mary's University; 2020. Available from:
Addis Ababa City Administration, Lideta Sub City Administration Annual Performance Report, 2022. Addis Ababa, Ethiopia. Unpublished.
[12]
Haile LM, Sinkie, Shimeles Ololo, Megerssa B. Willingness to Pay for Community-Based Health Insurance among Rural Households of Southwest Ethiopia [Internet]. arXiv.org. 2019 cited 2025 Jan 10]. Available from:
Kokebie, M. A., Abdo, Z. A., Mohamed, S. et al. Willingness to pay for social health insurance and its associated factors among public servants in Addis Ababa, Ethiopia: a cross-sectional study. BMC Health Serv Res 22, 909 (2022).
Mekuria M, Girma T. Community-based health insurance coverage: Drop-out rates and associated factors among households in selected districts of West Shewa Zone, Ethiopia. 2020. Available From:
Mekonne A, Seifu B, Hailu C, Atomsa A. Willingness to pay for social health insurance and associated factors among health care providers in Addis Ababa, Ethiopia. Bio Med research international. 2020.
Mulat, A. K., Mao, W., Bharali, I. et al. Scaling up community-based health insurance in Ethiopia: a qualitative study of the benefits and challenges. BMC Health Serv Res 22, 473 (2022).
Tahir, A., Abdilahi, A. O. & Farah, A. E. Pooled coverage of community based health insurance scheme enrolment in Ethiopia, systematic review and meta-analysis, 2016–2020. Health Econ Rev 12, 38 (2022).
Bayked EM, Toleha HN, Chekole BB, Workneh BD, Kahissay MH. Willingness to pay for social health insurance in Ethiopia: A systematic review and meta-analysis. Front Public Health. 2023 Mar 22; 11: 1089019.
Gidey MT, Gebretekle GB, Hogan M-E, Fenta TG. Willingness to pay for social health insurance and its determinants among public servants in Mekelle City, Northern Ethiopia: a mixed methods study. Cost Effectiveness and Resource Allocation. 2019; 17: 1-11. Available From:
Chiwire P, Evers SM, Mahomed H, Hiligsmann M. Willingness to pay for primary health care at public facilities in the Western Cape Province, Cape Town, South Africa. J Med Econ. 2021 Jan-Dec; 24(1): 162-172.
Regassa Z, Negera E, Silashi T, Kaba Z, Mosisa G. Willingness to join and pay social health insurance and associated factors among public sectors workers in Didu Woreda, South West Ethiopia, 2018. J Public Health Res. 2022 Sep 28; 11(3): 22799036221123957.
Mekonnen Degie F, Agumas Ambelie Y, Mulu Gelaw Y, Fentaw Mulaw G, Wassie Feleke F. Willingness to pay for social health insurance and its predictors among government employees in Mujja Town, Ethiopia. The Scientific World Journal. 2021; 2021: 1-7. Available From:
Batbold, O., Pu, C. Willingness to pay for private health insurance among workers with mandatory social health insurance in Mongolia. Int J Equity Health 20, 7 (2021).
Jufare, G., Tesfahun, A., Taresa, A., Haile, L. (2025). Willingness to Pay for Social Health Insurance and Associated Factors Among Public Servants in Lideta Sub-city; Addis Ababa, Ethiopia. Biomedical Statistics and Informatics, 10(2), 22-30. https://doi.org/10.11648/j.bsi.20251002.11
Jufare, G.; Tesfahun, A.; Taresa, A.; Haile, L. Willingness to Pay for Social Health Insurance and Associated Factors Among Public Servants in Lideta Sub-city; Addis Ababa, Ethiopia. Biomed. Stat. Inform.2025, 10(2), 22-30. doi: 10.11648/j.bsi.20251002.11
Jufare G, Tesfahun A, Taresa A, Haile L. Willingness to Pay for Social Health Insurance and Associated Factors Among Public Servants in Lideta Sub-city; Addis Ababa, Ethiopia. Biomed Stat Inform. 2025;10(2):22-30. doi: 10.11648/j.bsi.20251002.11
@article{10.11648/j.bsi.20251002.11,
author = {Getachew Jufare and Alemu Tesfahun and Asefa Taresa and Lakech Haile},
title = {Willingness to Pay for Social Health Insurance and Associated Factors Among Public Servants in Lideta Sub-city; Addis Ababa, Ethiopia
},
journal = {Biomedical Statistics and Informatics},
volume = {10},
number = {2},
pages = {22-30},
doi = {10.11648/j.bsi.20251002.11},
url = {https://doi.org/10.11648/j.bsi.20251002.11},
eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.bsi.20251002.11},
abstract = {Background: More than 4 billion people worldwide still lack social protection. However, the policy provides a framework for collaboration and coordination within the social protection system, aiming to deliver various services through an organized structure at all levels. Therefore, the aim of this study was to assess willingness to pay for social health insurance and its associated factors among public servants in Lideta Sub-city; Addis Ababa, Ethiopia. Methods: An institutional-based cross-sectional study was conducted from September 15 to November15/2023 using systematic random sampling among 381 permanent public servants in Lideta sub-city of Addis Ababa Ethiopia. Participants were interviewed using a structured pretested closed questionnaire to obtain detail data from respondents for different variables. The data was entered into the Kobo toolbox and exported to SPSS version 26.00 for analysis. Descriptive analysis and cross tabulation was done to see the picture of the data. Bivariate and multivariate logistic regression analysis was done at 95% of confidence interval. Those variables with P-value less than 0.05 along with their Adjusted Odds Ratio (AOR) were declared as a predictor of the outcome variables in the study. Results: A total of 381 government employees completed the questionnaire with a response rate of 100 %. Overall, 64.3% of respondents were willing to pay the proposed premium (3% of their monthly salary). Public servant who knew social health insurance scheme [AOR= 2.24, (95% CI: 1.31, 3.82)], those have good knowledge [AOR= 4.23, (95% CI: 2.15, 8.32)], those had a history of chronic disease [AOR= 2.46, (95% CI: 1.16, 5.21)] were associated with willingness to pay for social health insurance. Conclusions: The willingness to pay 3% of the monthly gross salary for social health insurance was 64.3 %. Public servant who knew social health insurance, having good knowledge and history of previous chronic diseases are identified as predictors of willingness to pay for social health insurance. Thus, the government of Ethiopia and Addis Ababa city administration recommended starting social health insurance. In addition qualitative study will be further recommended to get the detail investigation.
},
year = {2025}
}
TY - JOUR
T1 - Willingness to Pay for Social Health Insurance and Associated Factors Among Public Servants in Lideta Sub-city; Addis Ababa, Ethiopia
AU - Getachew Jufare
AU - Alemu Tesfahun
AU - Asefa Taresa
AU - Lakech Haile
Y1 - 2025/04/10
PY - 2025
N1 - https://doi.org/10.11648/j.bsi.20251002.11
DO - 10.11648/j.bsi.20251002.11
T2 - Biomedical Statistics and Informatics
JF - Biomedical Statistics and Informatics
JO - Biomedical Statistics and Informatics
SP - 22
EP - 30
PB - Science Publishing Group
SN - 2578-8728
UR - https://doi.org/10.11648/j.bsi.20251002.11
AB - Background: More than 4 billion people worldwide still lack social protection. However, the policy provides a framework for collaboration and coordination within the social protection system, aiming to deliver various services through an organized structure at all levels. Therefore, the aim of this study was to assess willingness to pay for social health insurance and its associated factors among public servants in Lideta Sub-city; Addis Ababa, Ethiopia. Methods: An institutional-based cross-sectional study was conducted from September 15 to November15/2023 using systematic random sampling among 381 permanent public servants in Lideta sub-city of Addis Ababa Ethiopia. Participants were interviewed using a structured pretested closed questionnaire to obtain detail data from respondents for different variables. The data was entered into the Kobo toolbox and exported to SPSS version 26.00 for analysis. Descriptive analysis and cross tabulation was done to see the picture of the data. Bivariate and multivariate logistic regression analysis was done at 95% of confidence interval. Those variables with P-value less than 0.05 along with their Adjusted Odds Ratio (AOR) were declared as a predictor of the outcome variables in the study. Results: A total of 381 government employees completed the questionnaire with a response rate of 100 %. Overall, 64.3% of respondents were willing to pay the proposed premium (3% of their monthly salary). Public servant who knew social health insurance scheme [AOR= 2.24, (95% CI: 1.31, 3.82)], those have good knowledge [AOR= 4.23, (95% CI: 2.15, 8.32)], those had a history of chronic disease [AOR= 2.46, (95% CI: 1.16, 5.21)] were associated with willingness to pay for social health insurance. Conclusions: The willingness to pay 3% of the monthly gross salary for social health insurance was 64.3 %. Public servant who knew social health insurance, having good knowledge and history of previous chronic diseases are identified as predictors of willingness to pay for social health insurance. Thus, the government of Ethiopia and Addis Ababa city administration recommended starting social health insurance. In addition qualitative study will be further recommended to get the detail investigation.
VL - 10
IS - 2
ER -
Jufare, G., Tesfahun, A., Taresa, A., Haile, L. (2025). Willingness to Pay for Social Health Insurance and Associated Factors Among Public Servants in Lideta Sub-city; Addis Ababa, Ethiopia. Biomedical Statistics and Informatics, 10(2), 22-30. https://doi.org/10.11648/j.bsi.20251002.11
Jufare, G.; Tesfahun, A.; Taresa, A.; Haile, L. Willingness to Pay for Social Health Insurance and Associated Factors Among Public Servants in Lideta Sub-city; Addis Ababa, Ethiopia. Biomed. Stat. Inform.2025, 10(2), 22-30. doi: 10.11648/j.bsi.20251002.11
Jufare G, Tesfahun A, Taresa A, Haile L. Willingness to Pay for Social Health Insurance and Associated Factors Among Public Servants in Lideta Sub-city; Addis Ababa, Ethiopia. Biomed Stat Inform. 2025;10(2):22-30. doi: 10.11648/j.bsi.20251002.11
@article{10.11648/j.bsi.20251002.11,
author = {Getachew Jufare and Alemu Tesfahun and Asefa Taresa and Lakech Haile},
title = {Willingness to Pay for Social Health Insurance and Associated Factors Among Public Servants in Lideta Sub-city; Addis Ababa, Ethiopia
},
journal = {Biomedical Statistics and Informatics},
volume = {10},
number = {2},
pages = {22-30},
doi = {10.11648/j.bsi.20251002.11},
url = {https://doi.org/10.11648/j.bsi.20251002.11},
eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.bsi.20251002.11},
abstract = {Background: More than 4 billion people worldwide still lack social protection. However, the policy provides a framework for collaboration and coordination within the social protection system, aiming to deliver various services through an organized structure at all levels. Therefore, the aim of this study was to assess willingness to pay for social health insurance and its associated factors among public servants in Lideta Sub-city; Addis Ababa, Ethiopia. Methods: An institutional-based cross-sectional study was conducted from September 15 to November15/2023 using systematic random sampling among 381 permanent public servants in Lideta sub-city of Addis Ababa Ethiopia. Participants were interviewed using a structured pretested closed questionnaire to obtain detail data from respondents for different variables. The data was entered into the Kobo toolbox and exported to SPSS version 26.00 for analysis. Descriptive analysis and cross tabulation was done to see the picture of the data. Bivariate and multivariate logistic regression analysis was done at 95% of confidence interval. Those variables with P-value less than 0.05 along with their Adjusted Odds Ratio (AOR) were declared as a predictor of the outcome variables in the study. Results: A total of 381 government employees completed the questionnaire with a response rate of 100 %. Overall, 64.3% of respondents were willing to pay the proposed premium (3% of their monthly salary). Public servant who knew social health insurance scheme [AOR= 2.24, (95% CI: 1.31, 3.82)], those have good knowledge [AOR= 4.23, (95% CI: 2.15, 8.32)], those had a history of chronic disease [AOR= 2.46, (95% CI: 1.16, 5.21)] were associated with willingness to pay for social health insurance. Conclusions: The willingness to pay 3% of the monthly gross salary for social health insurance was 64.3 %. Public servant who knew social health insurance, having good knowledge and history of previous chronic diseases are identified as predictors of willingness to pay for social health insurance. Thus, the government of Ethiopia and Addis Ababa city administration recommended starting social health insurance. In addition qualitative study will be further recommended to get the detail investigation.
},
year = {2025}
}
TY - JOUR
T1 - Willingness to Pay for Social Health Insurance and Associated Factors Among Public Servants in Lideta Sub-city; Addis Ababa, Ethiopia
AU - Getachew Jufare
AU - Alemu Tesfahun
AU - Asefa Taresa
AU - Lakech Haile
Y1 - 2025/04/10
PY - 2025
N1 - https://doi.org/10.11648/j.bsi.20251002.11
DO - 10.11648/j.bsi.20251002.11
T2 - Biomedical Statistics and Informatics
JF - Biomedical Statistics and Informatics
JO - Biomedical Statistics and Informatics
SP - 22
EP - 30
PB - Science Publishing Group
SN - 2578-8728
UR - https://doi.org/10.11648/j.bsi.20251002.11
AB - Background: More than 4 billion people worldwide still lack social protection. However, the policy provides a framework for collaboration and coordination within the social protection system, aiming to deliver various services through an organized structure at all levels. Therefore, the aim of this study was to assess willingness to pay for social health insurance and its associated factors among public servants in Lideta Sub-city; Addis Ababa, Ethiopia. Methods: An institutional-based cross-sectional study was conducted from September 15 to November15/2023 using systematic random sampling among 381 permanent public servants in Lideta sub-city of Addis Ababa Ethiopia. Participants were interviewed using a structured pretested closed questionnaire to obtain detail data from respondents for different variables. The data was entered into the Kobo toolbox and exported to SPSS version 26.00 for analysis. Descriptive analysis and cross tabulation was done to see the picture of the data. Bivariate and multivariate logistic regression analysis was done at 95% of confidence interval. Those variables with P-value less than 0.05 along with their Adjusted Odds Ratio (AOR) were declared as a predictor of the outcome variables in the study. Results: A total of 381 government employees completed the questionnaire with a response rate of 100 %. Overall, 64.3% of respondents were willing to pay the proposed premium (3% of their monthly salary). Public servant who knew social health insurance scheme [AOR= 2.24, (95% CI: 1.31, 3.82)], those have good knowledge [AOR= 4.23, (95% CI: 2.15, 8.32)], those had a history of chronic disease [AOR= 2.46, (95% CI: 1.16, 5.21)] were associated with willingness to pay for social health insurance. Conclusions: The willingness to pay 3% of the monthly gross salary for social health insurance was 64.3 %. Public servant who knew social health insurance, having good knowledge and history of previous chronic diseases are identified as predictors of willingness to pay for social health insurance. Thus, the government of Ethiopia and Addis Ababa city administration recommended starting social health insurance. In addition qualitative study will be further recommended to get the detail investigation.
VL - 10
IS - 2
ER -
Share This Article
Twitter
Linked In
Facebook
Copy
Download