Within the context of the Sustainable Development Goals, it is important to critically review research on healthcare financing in sub-Saharan Africa (SSA) from the perspective of the universal health coverage (UHC) goals of financial protection and access to quality health services for all. There is a concerning reliance on direct out-of-pocket payments in many SSA countries, accounting for an average of 36% of current health expenditure compared to only 22% in the rest of the world. Contributions to health insurance schemes, whether voluntary or mandatory, contribute a small share of current health expenditure. While domestic mandatory prepayment mechanisms (tax and mandatory insurance) is the next largest category of healthcare financing in SSA (35%), a relatively large share of funding in SSA (14% compared to <1% in the rest of the world) is attributable to, sometimes unstable, external funding sources. There is a growing recognition of the need to reduce out-of-pocket payments and increase domestic mandatory prepayment financing to move towards UHC. Many SSA countries have declared a preference for achieving this through contributory health insurance schemes, particularly for formal sector workers, with service entitlements tied to contributions. Policy debates about whether a contributory approach is the most efficient, equitable and sustainable means of financing progress to UHC are emotive and infused with “conventional wisdom.” A range of research questions must be addressed to provide a more comprehensive empirical evidence base for these debates and to support progress to UHC.

BackgroundThe Ethiopian health system has been undergoing through reforms. One of the reforms stipulated in policy documents is the introduction of health insurance at national level. Having the majority of the population without any experience of health insurance, investigating preferences and knowledge of the essence of health insurance among potential enrolees will provide vital information for policy makers. This formative study seeks to explore the knowledge and the preference for health insurance among formal sector employees in Addis Ababa.MethodsSix focus group discussions with formal sector employees and five key informant interviews were conducted in Addis Ababa. A thematic analysis is used to analyse the results.ResultsThe findings suggest that there is little knowledge about the concept and elements of health insurance. Some concepts such as, risk pooling and sharing are not well understood. The participants of the study considered health insurance as only a prepayment mechanism without risk sharing among members of the scheme. Regarding preference for health insurance, they have revealed quality of care as the most important factor. Comprehensiveness of benefit packages and the amount of premium level are also found to be concerns related to health insurance. However, a trade-off is also observed among premium level, comprehensive benefit packages, and healthcare facilities.ConclusionsImprovements on availability and quality of services need to precede the introduction of social health insurance. There is also a need to work on awareness creation regarding concepts of health insurance. Further studies may explore if the knowledge gap is real or appeared due to reservations of the participants on the introduction of health insurance.

As low-income countries are initiating health insurance schemes, Ethiopia is also planning to move away from out-of-pocket private payments to health insurance. The success of such a policy depends on understanding and predicting preferences of potential enrolees. This is because a scarce health care budget forces providers and consumers to make trade-offs between potential benefits within a health insurance. An assessment of preferences of potential enrolees can therefore add important information to optimal resource allocation in the design of health insurance. We used a discrete choice experiment to elicit preferences for social health insurance (SHI) among formal sector employees in Ethiopia. Respondents were presented with 18 binary hypothetical choices of SHI. Each insurance package was described by eight policy relevant attributes: premium, enrolment, exclusions, providers and coverage of inpatient services, outpatient services, drugs and tests. A mixed logit model was estimated to determine respondents' willingness to pay (WTP) for the different health insurance attributes. We also predicted probabilities of uptake for alternative SHI scenarios. Health insurance packages with 'no exclusions', 'public and private' providers, low rate of premium and full coverage of tests and drugs were highly valued and had greatest impact on the choices . Other things being equal, respondents were willing to contribute 1.52% (95% confidence interval (CI): 0.71, 2.32) of their salary to a SHI package with no service exclusions having public and private service providers. This is substantially lower than the proposed 3% premium in the draft SHI strategy. For the typical SHI package proposed by the SHI strategy at the time, the uptake probability was predicted to be 29% (95% CI: 0.25, 0.33). The low uptake probability and WTP for the proposed SHI package suggests considering preferences of the potential enrolees' in revisions of the draft SHI strategy for introduction of optimal SHI scheme would enhance acceptance.

Access to and utilisation of quality healthcare promotes positive child health outcomes. However, to be optimally utilised, the healthcare system needs to be responsive to the expectations of the population it serves. Health systems in many sub-Saharan African countries, including Malawi, have historically focused on promoting access to health services by the rural poor. However, in the context of increasing urbanisation and consequent proliferation of urban slums, promoting health of children under five years of age in these settings is a public health imperative. We conducted a discrete choice experiment to determine the relative importance of health facility factors in seeking healthcare for childhood illnesses in urban slums of Malawi. Caregivers of children under five years of age were presented with choice cards that depicted two hypothetical health facilities using six health facility attributes: availability of medicines and supplies, thoroughness of physical examination of the child, attitude of health workers, cost, distance, and waiting time. Caregivers were asked to indicate the health facility they would prefer to use. A mixed logit model was used to estimate the relative importance of and willingness to pay (WTP) for health facility attributes. Attributes with greatest influence on choice were: availability of medicines and supplies (β = 0.842, p<0.001) and thorough examination of the child (β = 0.479, p <0.001) with WTP of MK3698.32 ($11) (95% CI: $8–$13) and MK2049.13 ($6) (95% CI: $3–$9) respectively. Respondents were willing to pay 1.8 and 2.4 times more for medicine availability over thorough examination and positive attitude of health workers respectively. Therefore, strengthening health service delivery system through investment in sustained availability of essential medicines and supplies, sufficient and competent health workforce with positive attitude and clinical discipline to undertake thorough examination, and reductions in waiting times have the potential to improve child healthcare utilization in the urban slums.