Factors influencing willingness to pay for compulsory social health insurance among informal sector workers in Kazakhstan

Abstract

In order to develop the solidarity of the population and employers in the sustainable development and efficiency of the national health system, as well as to eliminate financial risks due to the growing public and private health costs, a system of compulsory social health insurance was introduced in 2016 in Kazakhstan. As a classic form of social health insurance the health services will be paid through payroll contributions from employer and employee, self-employed individuals and the government. The main problem is the large number of self-employed people for whom contributions are not made. Into this category includes more than 2 million people. Of these, 503 374 persons are young people.26 Lack of health insurance coverage in Kazakhstan among informal workers can impedes access to health care. Lack of health insurance is also can be a major cause of poverty. The main objective of this study was to assess informal workers willingness to join a social health insurance (SHI) model in Oskemen, East Part of Kazakhstan, and to determine factors influencing this willingness. A second objective was to identify informal workers willingness to pay according contribution level and their payment ability. The study was cross-sectional in design and conducted between August 2019 and October 2019 in Oskemen city and adjacent village Samsonovka. We elicit the WTP using the double bounded dichotomous choice (DBDC) elicitation method was used to estimate respondents WTP for proposed health insurance premium. The study participants were randomly selected by two-stage cluster sampling. Adequate sample size of 195 was calculated as optimal based on a 5% margin of error and a 95% confidence interval for a population of 1.5 million and was adjusted to accommodate an expected 80% response rate. From the 195 participants, 161 participated in the interview, making a response rate of 82%. The sex of participants was equally distributed 80(100,0%) were females and 81(100,0%) were males, their mean (± SD) age was 33,86 (± 11,673) years, ranging from 19 to 60. The monthly average income of participants (40%) was 85 000 tenge (US218$) ranging from 40000 tenge to 90000 tenge (US 103$ - 230$) respectively. Informal workers who are aware 2.5 times more likely to pay (p-value 0.022) the second bit than person who is not aware. Also, Trust level for SHI was significant and the person who does not trust on SHI system and improvement in the Health Care system after introducing SHI 4.2 times less likely to pay (p-value 0.021) contribution rates compare to who does. In addition, monthly income and expenditure were statistically significant (p-value <0,005). The person who have monthly income between 40.000 tenge and – 90.000 tenge, which is lower the average monthly wage in this region, 5.8 times are more likely to pay for the second bit than the higher income group informal workers 500.000 tenge and higher. Also informal workers who are earning monthly from 90.000 tenge to 200.000 tenge 4.3 times are more likely to make contribution than the higher income group. In addition the Health Care Expenditure for the last month positively correlated with the willingness to pay (p-value 0.028). In addition, monthly household expenditure was statistically significant (p-value < 0,005) and the Logistic regression analysis is interpreted in the informal workers who is spending from 90.000 tenge to 200.000 tenge, which is equal to average wage in this region, 17,6 times more likely to pay than who are spending two times higher (500.000 tenge and high) The majority of the informal workers were willing to enroll the social health insurance scheme, with a mean of WTP of 2% of their average monthly salary. This was lower than the premium proposed by the government (35%).Our results suggest that the contribution rate for informal workers should be revised according to income level of regions and geographical location of informal workers. Also, it is important to provide Educational Campaigns for rural dwellers and for people who doesn’t have access to media equipment’s. Because the willingness to pay is positively correlated with SHI awareness and Trust level on the system.