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      Willingness-to-Pay for Community-Based Health Insurance among Informal Workers in Urban Bangladesh

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          Abstract

          Introduction

          Reliance on out-of-pocket payment for healthcare may lead poor households to undertake catastrophic health expenditure, and risk-pooling mechanisms have been recommended to mitigate such burdens for households in Bangladesh. About 88% of the population of Bangladesh depends on work in the informal sector. We aimed to estimate willingness-to-pay (WTP) for CBHI and identify its determinants among three categories of urban informal workers rickshaw-pullers, shopkeepers and restaurant workers.

          Methods

          The bidding game version of contingent valuation method was used to estimate weekly WTP. In three urban locations 557 workers were interviewed using a structured questionnaire during 2010 and 2011. Multiple-regression analysis was used to predict WTP by demographic and household characteristics, occupation, education level and past illness.

          Results

          WTP for a CBHI scheme was expressed by 86.7% of informal workers. Weekly average WTP was 22.8 BDT [Bangladeshi Taka; 95% confidence interval (CI) 20.9–24.8] or 0.32 USD and varied significantly across occupational groups (p = 0.000) and locations (p = 0.003). WTP was highest among rickshaw-pullers (28.2 BDT or 0.40 USD; 95% CI: 24.7–31.7), followed by restaurant workers (20.4 BDT 0.29 USD; 95% CI: 17.0–23.8) and shopkeepers (19.2 BDT or 0.27 USD; 95% CI: 16.1–22.4). Multiple regression analysis identified monthly income, occupation, geographical location and educational level as the key determinants of WTP. WTP increased 0.196% with each 1% increase in monthly income, and was 26.9% lower among workers with up to a primary level of education versus those with higher than primary, but less than one year of education.

          Conclusion

          Informal workers in urban areas thus are willing to pay for CBHI and socioeconomic differences explain the magnitude of WTP. The policy maker might think introducing community-based model including public-community partnership model for healthcare financing of informal workers. Decision making regarding the implementation of such schemes should consider worker location and occupation.

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          Most cited references25

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          Community-based health insurance in low-income countries: a systematic review of the evidence.

          B Ekman (2004)
          Health policy makers are faced with competing alternatives, and for systems of health care financing. The choice of financing method should mobilize resources for health care and provide financial protection. This review systematically assesses the evidence of the extent to which community-based health insurance is a viable option for low-income countries in mobilizing resources and providing financial protection. The review contributes to the literature on health financing by extending and qualifying existing knowledge. Overall, the evidence base is limited in scope and questionable in quality. There is strong evidence that community-based health insurance provides some financial protection by reducing out-of-pocket spending. There is evidence of moderate strength that such schemes improve cost-recovery. There is weak or no evidence that schemes have an effect on the quality of care or the efficiency with which care is produced. In absolute terms, the effects are small and schemes serve only a limited section of the population. The main policy implication of the review is that these types of community financing arrangements are, at best, complementary to other more effective systems of health financing. To improve reliability and validity of the evidence base, analysts should agree on a more coherent set of outcome indicators and a more consistent assessment of these indicators. Policy makers need to be better informed as to both the costs and the benefits of implementing various financing options. The current evidence base on community-based health insurance is mute on this point.
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            Good Health at Low Cost 25 years on: lessons for the future of health systems strengthening.

            In 1985, the Rockefeller Foundation published Good health at low cost to discuss why some countries or regions achieve better health and social outcomes than do others at a similar level of income and to show the role of political will and socially progressive policies. 25 years on, the Good Health at Low Cost project revisited these places but looked anew at Bangladesh, Ethiopia, Kyrgyzstan, Thailand, and the Indian state of Tamil Nadu, which have all either achieved substantial improvements in health or access to services or implemented innovative health policies relative to their neighbours. A series of comparative case studies (2009-11) looked at how and why each region accomplished these changes. Attributes of success included good governance and political commitment, effective bureaucracies that preserve institutional memory and can learn from experience, and the ability to innovate and adapt to resource limitations. Furthermore, the capacity to respond to population needs and build resilience into health systems in the face of political unrest, economic crises, and natural disasters was important. Transport infrastructure, female empowerment, and education also played a part. Health systems are complex and no simple recipe exists for success. Yet in the countries and regions studied, progress has been assisted by institutional stability, with continuity of reforms despite political and economic turmoil, learning lessons from experience, seizing windows of opportunity, and ensuring sensitivity to context. These experiences show that improvements in health can still be achieved in countries with relatively few resources, though strategic investment is necessary to address new challenges such as complex chronic diseases and growing population expectations. Copyright © 2013 Elsevier Ltd. All rights reserved.
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              Willingness-to-pay for community-based insurance in Burkina Faso.

              To study the willingness-to-pay (WTP) for a proposed community-based health insurance (CBI) scheme in order to provide information about the relationship between the premium that is required to cover the costs of the scheme and expected insurance enrollment levels. In addition, factors that influence WTP were to be identified. Data were collected from a household survey using a two-stage cluster sampling approach, with each household having the same probability of being selected. Interviews were conducted with 2414 individuals and 705 household heads. The take-it-or-leave-it (TIOLI) and the bidding game were used to elicit WTP. The average individual was willing to pay 2384 (elicited by the TIOLI) or 3191 (elicited by the bidding game) CFA (3.17 US dollars or 4.25 US dollars) to join CBI for him/herself. The head of household agreed to pay from 6448 (elicited by the TIOLI) or 9769 (elicited by the bidding game) CFA (8.6 US dollars or 13.03 US dollars) to join the health insurance scheme for his/her household. These results were influenced by household and individual ability-to-pay, household and individual characteristics, such as age, sex and education. The two methods yielded similar patterns of estimated WTP, in that higher WTP was obtained for higher income level, higher previous medical expenditure, higher education, younger people and males. A starting point bias was found in the case of the bidding game. Both TIOLI and bidding game methods can elicit a value of WTP for CBI. The value elicited by the bidding game is higher than by the TIOLI, but the two approaches yielded similar patterns of estimated WTP. WTP information can be used for setting insurance premium. When setting the premiums, it is important to consider differences between the real market and the theoretical one, and between the WTP and the cost of benefits package. The beneficiaries of CBI should be enrolled at the level of households or villages in order to protect vulnerable groups such as women, elders and the poor. Copyright 2002 John Wiley & Sons, Ltd.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                1 February 2016
                2016
                : 11
                : 2
                : e0148211
                Affiliations
                [1 ]Health Economics & Financing Research Group, Centre for Equity and Health Systems, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
                [2 ]Health Economics and Policy Research Group, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
                [3 ]School of Population Health, University of Queensland, Brisbane, Australia
                [4 ]James P Grant School of Public health, BRAC University and International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
                [5 ]Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, United Kingdom
                New York University, UNITED STATES
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: SA MEH JAMK. Performed the experiments: SA JAMK MEH. Analyzed the data: SA MEH ARS MS ZI RG JAMK. Contributed reagents/materials/analysis tools: SA MEH ARS MS ZI RG JAMK. Wrote the paper: SA MEH ARS MS ZI RG JAMK.

                Article
                PONE-D-15-06617
                10.1371/journal.pone.0148211
                4734618
                26828935
                09e2dc56-194b-48ae-a287-ff8f7fd94093
                © 2016 Ahmed et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 19 February 2015
                : 14 January 2016
                Page count
                Figures: 1, Tables: 6, Pages: 16
                Funding
                This work was supported by the International Labor Organization and Microinsurance Innovation Facility. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Social Sciences
                Economics
                Health Economics
                Health Insurance
                Medicine and Health Sciences
                Health Care
                Health Economics
                Health Insurance
                People and Places
                Geographical Locations
                Asia
                Bangladesh
                Social Sciences
                Economics
                Finance
                People and Places
                Population Groupings
                Professions
                Social Sciences
                Economics
                Commerce
                Payment
                Social Sciences
                Economics
                Health Economics
                Medicine and Health Sciences
                Health Care
                Health Economics
                Social Sciences
                Sociology
                Education
                Educational Attainment
                Medicine and Health Sciences
                Health Care
                Socioeconomic Aspects of Health
                Medicine and Health Sciences
                Public and Occupational Health
                Socioeconomic Aspects of Health
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