Willingness to pay for social health insurance and associated factors among government employees in Jigjiga, Eastern Ethiopia: Mixed Method Study

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A million people suffer a health-related financial catastrophe each year, and the majority have difficulty paying health expenditures, which leads government employees to low health service utilization. However, there is no evidence of the status of health insurance in the study area. Therefore, the study aimed to assess willingness to pay for social health insurance and associated factors among government employees, in Jigjiga town, eastern Ethiopia. Method : A mixed method cross-sectional study was used among 578 randomly selected government employees from March 30 to May 30, 2023, in Jigjiga city. Data was collected using a pre-tested semi-structured questionnaire through self-administration, entered into Epi-data version 3.1, and exported to SPSS version 22.0. Binary logistic regression was conducted to identify factors associated with willingness to pay. An odds ratio with a 95% confidence interval was used to interpret the finding and statistical significance was set at p 39 years old [AOR=6.30, 95 % CI;2.23,17.86], masters and above educational [AOR=0.41, 95% CI; 0.17,0.98], family size >=5 [AOR=0.11, 95% CI; 0.03,0.39], chronic illness in a family [AOR=0.37, 95 % CI; 0.25,0.55], and belief social health insurance as no benefit [AOR= 0.26, 95 % CI; 0.08,0.85] were significantly associated with social health insurance. From in-depth interviews, social health insurance has high acceptance and is considered an appropriate program for the study area. Conclusion : Nearly seven out of ten government employees are willing to pay for the proposed SHI. Age, educational status, family size, presence of chronic disease, and belief in SHI benefits are associated with willingness. A strong emphasis on implementation and providing necessary information for employees should be given to enhance their knowledge. It would be better to advocate the SHI for policymakers in order to start early implementation of the SHI in the Somali region. Health sciences/Anatomy Health sciences/Health care Health sciences/Health occupations Government employee health insurance social security Ethiopia Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Social health insurance (SHI) increases public purchasing of health services, promoting quality and financial protection ( 1 , 2 ). The SHI is a powerful mechanism for raising and pooling funds to finance health services, private health insurance, community insurance, and others in developing countries ( 3 ). Enrollment in SHI is compulsory and the proposed contribution is 3% of their salary ( 4 ). Globally, 930 million people have suffered catastrophic healthcare spending and 90 million have been pushed into extreme poverty due to out-of-pocket (OOP) health expenditures. Specifically, in low and middle-income countries, 150 million people suffer a financial catastrophe each year due to out-of-pocket (OOP) health expenditures ( 5 , 6 ). Low-income countries lack adequate funding for health care due to high reliance on OOP payment and development assistance ( 7 ). In Ethiopia, healthcare financing is a major challenge, with 5.4% government expenditure which is below the targets set by the Abuja Declaration of 15% and 90% funded from household OOP expenditure ( 8 , 9 ). Social health insurance is important for reducing financial barriers, providing special attention to the poor community, and promoting universal health coverage and equity. It also reduces catastrophic health spending and improves access and utilization of health care, improving overall health outcomes ( 10 , 11 ). In addition, health financing reduces catastrophic health spending, improves access and utilization of health care, and improves overall health outcomes ( 12 , 13 ). Implementation of SHI is challenging in many countries due to factors such as readiness, acceptance, quality, the strength of health information systems, and awareness ( 14 ). Moreover, the studies from countries reported several factors associated with willingness to pay for social health insurance such as educational status, income, history of difficulty, and other sources associated with willingness to pay (WTP) for social health insurance( 15 ). The Ethiopian Federal Ministry of Health (FMOH) began healthcare financing reform in 1998 to improve and diversify resource mobilization for health and secure financial protection for citizens implementing a health insurance scheme was one of nine intervention strategies mentioned in this reform ( 16 ). Furthermore, the Ethiopian government created two different types of health insurance strategies: social health insurance, which was planned to be implemented in 2014; under this strategy, active employees will be required to pay monthly premiums of 3%, while pensioners will be required to pay 1% of their monthly salary ( 4 , 17 ). Despite the globally expanded coverage of essential health services continuing, it is not enough to meet the targets ( 18 ), and more than 32% of developing country health expenditure comes from out-of-pocket payments, which has an impact on universal health coverage (UHC), which provides access to quality essential health services ( 19 ). Though few studies were conducted in Ethiopia ( 20 – 22 ) the findings related to social health insurance and its determinants among civil servants were not well articulated, and the previous study focused on a single government organization and used only quantitative methods. In addition, SHI is not yet implemented in all regions of the country, and evidence from qualitative and quantitative studies from all government organizations was needed to predict the willingness to pay for SHI among all government employees. There was no study has been conducted in the Somali regional state about willingness to pay for social health insurance. Therefore, the current study was aimed to assess the willingness to pay for social health insurance and associated factors among government employees in Jigjiga, eastern Ethiopia. Method and Materials Study design, area, and period A mixed-methods cross-sectional study was conducted among government employees from March 30 to May 20, 2023, in Jigjiga town, Somalia, in eastern Ethiopia. Jigjiga Town is the capital city of the Somalia regional states and is located around 638 km away from the capital city of the county, Addis Ababa. According to the Ethiopian Central Statistical Agency (CSA) data for 2022, the total population of Jigjiga town was 197,966 and had 43 organizations. There are 7,158 government employees and 2236 health workers. The town had 1 referral hospital, 1 regional hospital, 1 primary hospital, four health centers, and 12 private clinics, consisting of around 2236 health workers. Study Participants All Jigjiga town permanent employees who are employed by the government permanently. Inclusion and exclusion criteria Those selected government employees in Jigjiga town who had worked for the government organization for more than six months were included; however, those who had been on leave annually, sick, maternity, and studied during the study period were excluded from the study. Sample Size determination The quantitative sample size was established for both specific objectives by using a single population proportion formula, considering the proportion and factors that affect WTP for SHI among government employees. The first objective sample size was calculated using the proportion of willingness for SHI among healthcare providers in Addis Ababa, Ethiopia (p = 0.35) (23). d = standard error or precision = 0.04; n = sample size to be calculated as follows: With the design effects of 1.5 and 10% non-response rates, the final sample size for objective one was 578. The sample size was also calculated for the second objective considering factors associated with WTP for SHI from previous (23, 24) studies by Epi-Info software version 7 (stat Cal) using a two-sided confidence level ratio (unexposed to exposed) = 1. Finally, the sample size calculated for the second objective was smaller than that for the first objective. Therefore, the sample size of the first objective is taken as the final sample size, which was 578. Qualitative study For qualitative research, nine in-depth interviews were conducted among organizational leaders. During the in-depth interview, we purposely selected only one participant for each organizational government. Furthermore, sampling was guided by the emerging concerns or issues from the previous interviews. Sampling procedures A multistage sampling method was used. There were 29 government organizations in Jigjiga town. Considering the WHO criteria for representation from all government organizations (25), nine government organizations were selected by the lottery method. After selecting nine government organizations, the proportional allocation was used to select study participants from each government organization (health, water, general auditor, education, revenue, finance, skill and work creation, urban construction and development, and postural development bureaus) using simple random sampling ( Figure 1). A purposive sampling technique was employed to select participants for qualitative interviews by considering maximum variability with the assumption of obtaining rich information for an in-depth interview. Data collection tool and procedures Quantitative data were collected from government employees using a standardized self-administered questionnaire adapted from different studies (24, 26), which has three parts (socio-demographic, healthcare-related, and health status characteristics). Data were collected by four BSc health workers supervised by two individuals after receiving two days of training on the purpose and procedure of recruiting government employees from each selected organization for this research by the principal investigator. Then an information sheet was provided for the head of the organization. After understanding the information sheet, the manager/head signed for the data to be collected. The data collectors took a questionnaire tool for participants and a volunteer-signed agreement for the data collection from each participant. Qualitative data was collected by three trained BSc nurses using an in-depth interview guide method, a tape recorder, and field notes to address contexts, behaviors, challenges, and reflections with a daily based activity by the supervisors. Data quality control For quantitative data, the standard questionnaire was prepared in English, translated to the local Somalia language for data collection, and then translated back into English. The data collectors were four BSC nurses selected from other health institutions and given two days of training. The questionnaire was pre-tested in another town, taking up five percent of the actual sample size. The supervisor was monitoring the completeness and consistency of the collected data along with the principal investigator on a daily basis on the spot during the data collection time. Double data entry was also done by two data clerks, and the consistency of the entered data was cross-checked. Regarding the qualitative data, an in-depth interview using an interview guide was developed in line with the objective of the study. An interview was conducted by experienced and trained data collectors. Conducting debriefing and discussion sessions each day during the entire fieldwork was encouraged to deal with any emerging issues. Facilitators’ and note-takers impressions were documented for each data source. In order to ensure that the interpretation of the finding made sense, debriefing discussions with advisors, supervisors, and data collectors were conducted. Operational definition s The level of WTP for SHI is volunteer to pay for the proposed first bid (3% of monthly salary) of the premium. For those who had never heard about SHI, information was given in detail about what SHI means, its objectives, and payment-related and healthcare-related issues before asking them about their willingness to pay. One question was prepared, which was answered by yes or no (24). Affordable health service costs: responses given to questions regarding the payment issue on previous illnesses asked would be yes if the participants were allowed to pay or no if they were not allowed to pay. Satisfaction with healthcare costs : the fulfilled client needs, as per the cost of healthcare or the cost of health service affordability level, to get treatment for their current illness (27). One question would be asked about the satisfaction of clients regarding the health care cost and answered by satisfied or unsatisfied. Awareness of SHI : the knowledge level about the SHI scheme and its importance and source of information among the individuals (28). A question such as Have you ever heard of SHI? Was evaluated by a yes-or-no answer Data processing and Analysis The quantitative data were checked for completeness and consistency by cross-checking, entered into Epi Data version 3.1, and then exported to SPSS version 22.0 for analysis. Descriptive statistics like mean and standard deviation were done and presented using frequency tables, figures, and graphs. A binary logistic regression was carried out to identify factors associated with WTP for SHI. Variables with a p-value less than 0.25 in the bi-variable logistic regression were considered for the multivariable binary logistic regression analysis to control for possible confounding factors. In the final multivariable binary logistic regression, the odds ratio along with the 95% confidence interval were used to present the association between explanatory variables and outcome variables at a p-value of less than 0.05. The goodness of model fit was checked by the Hosmer-Lemeshow statistic. Multi-collinearity tests were carried out to see the correlation between independent variables and checked by using the standard error and collinearity statistics (variance inflation factors > 10 and standard error > 2), which were considered suggestive of the existence of multi-collinearity. Qualitative data collected from audio records and field notes was transcribed in Somalia and translated into English. The translated documents were imported into Atlas. ti 7 software for analysis. Coding and categorization were done to form primary themes, both inductively and based on predetermined concepts and objectives of the study. Besides, quotes from participants’ expressions that exemplify key concepts were used directly during analysis and interpretation. Finally, the result was triangulated with the quantitative results and discussions. Results Socio-demographic characteristics of respondents This study included 578 government workers in total, with a 100% response rate. The respondents' ages varied from 20 to 49 years, with an average (+ SD) age of 34.95 (+ 6.43). Males made up the majority of respondents, 414 (71.6%), and 396 (68.5%) identified as Muslims. The majority of respondents, 466 (80.6%), had a first degree, and almost half of them, 263 (45.5%), were married, and 261 (45.2%) respondents had less than two family members. 508 (87.9%) of the respondents had an average monthly income of between 5,000 and 10,000 Ethiopian birr (Table 1 ). The most dominant profession of the study participants was management and accounting (26.1%) (Fig. 2 ). Table 1 Socio-demographic and economic characteristics of a government employee in Jigjiga town, eastern Ethiopia, 2023. Variables n = 578 Categories Frequency Percent (%) Age categories of respondents 20–24 28 4.8 25–29 94 16.3 30–34 220 38.1 35–39 69 11.9 > 39 167 28.9 Sex Male 414 71.6 Female 164 28.4 Religion Muslim 396 68.5 Orthodox 178 30.8 Protestant 4 .7 Ethnicity Somali 357 61.8 Amhara 203 35.1 Oromo 18 3.1 Marital Status Married 263 45.5 Single 226 39.1 Divorced 61 10.6 Widowed 28 4.8 Educational level Certificate and Diploma 66 11.4 First degree 466 80.6 Master’s and Above 46 8.0 Family size 1–2 261 45.2 3–4 139 24.0 > 4 178 30.8 Presence of under 5 years children Yes 329 56.9 No 249 43.1 Presence of between 6–18 years children Yes 301 52.1 No 277 47.9 Family monthly income <=5000 70 12.1 5000–10000 508 87.9 Health status and health service utilization characteristics of respondents A majority of 476 (82.4%) of study respondents had no history of chronic illness. However, more than half, 324 (56.1%) of participants, reported the presence of chronic illness in their family members. Regarding the treatment-seeking behavior for the recent episode of illness, 444 (76.8%) of the study participants sought treatment. More than half, 306 (52.9%) of participants, preferred public health facilities for illness treatment. 353 (61.1%) of study participants were afforded health care costs, and about half, 287 (49.7%) of them were satisfied with the cost of health services ( Table 2 ). Out of the total respondents, about half (50.17%) of them had a government-sourced health expenditure (Fig. 3 ). Table 2 Health status and health service utilization characteristics of a government employee in Jigjiga town, eastern Ethiopia, 2023 Variables n = 578 Categories Frequency Percent (%) History of chronic illness Yes 102 17.6 No 476 82.4 Presence of chronic illness among family members Yes 324 56.1 No 254 43.9 Seeking treatment for the recent episode of illness Yes 444 76.8 No 134 23.2 Place of treatment sought Public health facility 306 52.9 Private health facility 193 33.4 Traditional healer 79 13.7 Affordability of health care costs Affordable 353 61.1 Not affordable 225 38.9 Satisfaction with the quality of services Satisfied 280 48.4 Neutral 226 39.1 Dissatisfied 72 12.5 Satisfaction with the cost of health service Satisfied 287 49.7 Neutral 208 36.0 Dissatisfied 83 14.4 Awareness of social health insurance schemes and health care related factors Nearly all 567 (98.1%) of the respondents had ever heard about SHI, and mass media 185 (32.0%) was the main source of information for SHI. Among those participants who had ever heard about social health insurance, 561 (97.1%) believed that social health insurance has benefits, and nearly half, 266 (46.0%) of participants believed that the benefit of SHI prevents unexpected health expenses. About half, 296 (51.2%) of respondents believe that SHI will create a workload on health facilities, and of them, 226 (39.1%) think they have lost interest in paying for SH (Table 3 ). Table 3 Awareness of social health insurance schemes and health care-related factors of government employees in Jigjiga town, easteren Ethiopia, 2023. Variables n = 578 Categories Frequency Percent (%) Ever heard of social health insurance scheme Yes 567 98.1 No 11 1.9 Source of information for the SHI scheme Mass media 185 32.0 Friends’ insurance agency 172 29.8 Working institution 153 26.5 Family 57 9.9 Believe that SHI has benefits Yes 561 97.1 No 17 2.9 Benefits of the SHI scheme Prevent unexpected health expend 266 46.0 Help others who can't afford the 138 23.9 Have timely care in times of ill 110 19.0 Improve health services quality 64 11.1 Quality of healthcare services Good 309 53.5 Medium 229 39.6 Bad 40 6.9 SHI will create a workload on health facilities Yes 296 51.2 No 282 48.8 Lost of interest in paying for SHI Yes 226 39.1 No 70 12.1 Willingness to pay for social health insurance In this study, 404 (69.90%; 95CI: 66.15, 73.65) of study participants had a willingness to pay for the proposed SHI scheme (3% of their gross monthly salary) (Fig. 4 ). Factors associated with WTP for the proposed SHI scheme In the final multivariable logistic regression model, the age of respondents, educational level, family size, presence of chronic illness in the family member, and belief in the SHI benefit were found to have a statistically significant association with willingness to pay for the proposed SHI scheme. Study respondents aged greater than 39 years old were 6.3 times more likely to be paid for SHI compared to those whose age was 20–24 years old (AOR = 6.30, 95% CI: 2.23–17.86). Participants with the educational level of master’s and above were less likely to pay for the SHI scheme by 59% compared to those who had a certificate and diploma (AOR = 0.41; 95% CI: 0.17–0.98). Willingness to pay for SHI was decreased by 89% in participants who had a family size of five or more compared to those who had one or two family members (AOR = 0.11, 95% CI: 0.03–0.39). Participants with the presence of chronic illness in their family members were less likely to pay for SHI by 63% compared with those who do not have (AOR = 0.37, 95% CI: 0.25–0.55). Furthermore, a willingness to pay for SHI was decreased by 74% among participants who believed the SHI scheme had no benefit compared to their counterparts (AOR = 0.26, 95% CI = 0.08–0.85) (Table 4 ). Table 4 Bi-variable and multivariable logistic regression analysis of factors associated with willingness to pay to SHI among a government employee in Jigjiga town, eastern Ethiopia, 2023 Variables (n = 578) Willingness to pay SHI COR (95%CI) AOR (95% CI) P-value No (%) Yes (%) Age categories in years 20–24 12(42.9) 16(57.1) 1 1 25–29 31( 33 ) 63(67) 1.52(0.64, 3.61) 1.58(0.62,4.02) 0.34 30–34 64(29.1) 156(70.9) 1.82(0.82,4.08) 2.28(0.93,5.58) 0.07 35 − 3 9 23(33.3) 46(66.7) 1.50(0.61,3.69) 2.62(0.91,7.52) 0.07 > 39 44(26.3) 123(73.7) 2.10(0.92,4.78) 6.30(2.23,17.86) 0.001** Marital status Married 89(33.8) 174(66.2) 1 1 Single 66(29.2) 160(70.8) 1.24(0.44,1.82) 0.52(0.15,1.82) 0.31 Divorced 13(21.3) 48(78.7) 1.89(0.97,3.67) 0.91(0.41,2.01) 0.81 Widowed 6(21.4) 22(78.6) 1.88(0.73,4.79) 0.94(0.32,2.75) 0.91 Educational level Certificate and diploma 23(34.8) 43(65.1) 1 1 First degree 126( 27 ) 340(72.9) 1.44(0.84,2.49) 1.15(0.61,2.17) 0.68 Masters and above 25(54.3) 21(45.7) 0.45(0.21,0.97) 0.41(0.17,0.98) 0.04* Family size 1–2 70(28.8) 191(73.1) 1 1 3–4 29(20.9) 110(79.1) 1.39(0.85,2.27) 0.43(0.13,1.47) 0.18 >=5 75(42.1) 103(57.9) 0.50(0.34,0.75) 0.11(0.03,0.39) 0.001** Family monthly income <=5000 28( 40 ) 42(60) 1 1 5000 − 1000 146(28.7) 362(71.2) 1.65(0.99,2.77) 1.70(0.92,3.13) 0.09 Presence of chronic disease in the family members Yes 71(21.9) 253(78.1) 1 1 No 103(40.6) 151(59.4) 0.41(0.29,0.59) 0.37(0.25,0.55) 0.000** Place of treatment Public health facility 100(28.1) 256(71.9) 1 1 Private health facility 68(34.5) 129(65.4) 0.74(0.51,1.08) 0.73(0.47,1.11) 0.14 Traditional healers 6( 24 ) 19(76) 1.24(0.48,3.19) 1.87(0.65,5.40) 0.25 Affordability of health care cost Affordable 99( 28 ) 254(71.9) 1 1 Not affordable 75(33.3) 150(66.7) 0.78(0.54,1.12) 0.90(0.59,1.37) 0.61 Satisfaction with the quality of health services Satisfied 83(29.6) 197(70.4) 1 1 Neutral 62(27.4) 164(72.6) 1.11(0.76,1.64) 1.27(0.81,1.99) 0.29 Dissatisfied 29(40.3) 43(59.7) 0.62(0.37,1.07) 0.56(0.30,1.04) 0.07 Ever heard about SHI Yes 168(29.6) 399(70.4) 1 1 No 6(54.5) 5(45.5) 0.35(0.11,1.17) 0.78(0.18, 3.47) 0.75 Believe that SHI has benefits Yes 164(29.2) 397(70.8) 1 1 No 10(58.8) 7(41.2) 0.29(0.11,0.77) 0.26(0.08,0.85) 0.03* *p-value < 0.05 **p-value < = 0.001 Qualitative findings A total of nine in-depth interviews (IDIs) were conducted, and two major themes (perceived effectiveness and challenges to implementing SHI) emerged from the thematic analysis: the perceived effectiveness theme with three subcategories (acceptability, perceived benefit, and appropriateness/reducing the risk of SHI) and challenges to implementing SHI with three subcategories (lack of knowledge of guiding principles, lack of a clear plan and implementation strategies, and poor quality health service perceptions) were identified. Perceived effectiveness of SHI Study participants explained that SHI is very welcomed, has the advantage of reducing out-of-pocket payments, narrowing the inequality of services, and is perceived as providing different services for both government employees and their family members, which relieves employees from high medical expenses. This implies that SHI implementation appears to be effective, as it has gained high acceptance and is considered an appropriate program in the area to benefit employees by reducing unexpected medical expenses (Table 5 ). Table 5 Shows qualitative findings, from IDI from government employees in Jigjiga town, eastern Ethiopia, 2023(N = 9 individuals across 4 female and 5 Male IDIs). Major themes with their sub categories on WTP of SHI Descriptions for the each categories themes (data-based) Supportive quotations (from the interviews) 1. Perceived effectiveness of SHI 1.1. Acceptability of SHI 1.2. perceived benefit to SHI 1.3. Appropriate/essential and reducing the risk. SHI is very welcomed and perceived as it provides different services for both government employees with their family members, which relieves employees from High medical expenses. Social health Insurance has the advantage of reducing out-of-pocket payment and narrowing the inequality in health service utilization among government employees. SHI is essential to get any type of service and it can reduce the risk related to service expenses at the household level “I am very welcome social health insurance because it provides great relief from high medical expenses for me and my entire family and enables us to use different health services (Male, 39 years old employee)”. “Social Health Insurance has the advantage of reducing unexpected out-of-pocket payments and narrowing the inequality in health service utilization among government employees. Now that the cost of medical services has escalated, it also helps through premium revision, price negotiation, and standardizing the sanction process in the health system (Male, 43 years old employee)”. “We government employees should need social health insurance because it covers health-related problems at a low cost and can protect or reduce the expenses for medical services when a family member becomes ill (Male, 40 years old employee)”. 2. Challenges to implementing the SHI 2.1. Lack of knowledge of guiding principles. 2.2. Lack of clear plan and implementation strategies 2.3. Poor quality health service perceptions Government employees have no knowledge regarding the SHI service standards, health policy & health care financing strategy. Overall no planned and implementation documents of SHI at the government sectors Government employees have no trust in the services provided by public health institutions and need to launch the program in the Somalia region. “We government employees have no knowledge regarding the presence of social health insurance structures and standards for regulating health services, and we also have no awareness regarding the availability of health policies and the health care financing strategy of social health insurance (Male, 39-years-old employee)”. “Still, there is no planning and implementation documents for SHI in government sectors, and it is difficult to understand who is responsible for social health insurance implementation (Female, 39 years old employee)”. “Governmental employees may not pay for social health insurance because it is a new implementation strategy in this Somali regional state, and we also have no trust in the quality of public health services because most of the time the health system sends patients to private institutions, especially for expensive services such as drugs, laboratory services, and others (Female, 37 years old employee)”. Challenges to implementing the SHI Implementing social health insurance in the study area faced challenges, but there were no plans or implementation documents. As a result, government employees do not know the SHI service standards, health policy, or health care financing strategy. Government employees have no trust in the services provided by public health institutions and need to launch the program in the study area. This implies that to implement SHI, providing planned and implementation documents for each sector would be enormously helpful in bringing good knowledge about it and provide quality service for the client, minimizing the challenges of a willingness to join the social health insurance program (Table 5 ). Discussion This study found that the overall magnitude of willingness to pay for social health insurance was 69.90% (CI: 66.15, 73.65%). Factors such as the age of respondents, educational level, family size, presence of chronic illness in the family member, and belief in SHI benefits were found to have a statistically significant association with willingness to pay for the proposed SHI scheme. This study revealed that the willingness to pay for SHI among permanent government employees was 69.90% which is analogous to the studies conducted in Bahir Dar City (66.6%) ( 14 ), Gondar City (62.0%) ( 29 ), and South Sudan (68.0%) ( 30 ). The study findings were higher than the previous studies conducted in Addis Ababa (28.7%) ( 31 ), Mujja town (36.6%) ( 32 ), Addis Ababa (35.4%) ( 26 ), and Gondar city (32.0%) ( 33 ). However, this finding is lower than the study done in the Harari region (89.5%) ( 34 ) and Mekelle City (85.3%) ( 35 ). This inconsistency can result from the difference in socio-demographic characteristics of study participants and the variation in study settings, time of the study, and sample size. It may also be due to the inconsistency in information dissemination, accessibility, awareness, and differences in the health and wealth status of the study participants. In our study, nearly all (98.1%) of the respondents had information about SHI. Our finding suggests that the willingness to pay for SHI may increase if the insurance sector effectively works on information dissemination and awareness creation. The study revealed that respondents older than 39 years old were 6.3 times more likely willing to pay for SHI as compared with those aged between 20–24 years old. This study in line with the study done in South Africa ( 36 ) and the Tigrai region ( 37 ). This could be explained by the fact that as age increases, the probability of getting different types of chronic diseases will increase, and due to those expected chronic diseases related to ageing, study participants may prefer to pay for SHI to frequently visit health institutions for health care services. Another possible reason may be related to the fact that older individuals may have been exposed to other insurance options in their lifetime, developed a positive attitude toward their benefits, and were therefore more likely to accept and use the new system. Additionally, it has also been discovered that older people are more willing to pay for a proposed SHI scheme than younger people ( 38 ). Our study showed that respondents with the educational level of master’s and above were less likely to be willing to pay for the SHI scheme by 59% compared to those who had a certificate and diploma. This finding is similar to the study conducted in Dessie city, north-east Ethiopia ( 39 ) and Mekelle city, Northern Ethiopia ( 35 ). However, this finding is in contrast with other similar studies that found that attending a higher level of education has a positive impact on willingness to pay for SHI: Yogyakarta Province, Indonesia ( 40 ), Sarawa, Malaysia ( 41 ), Gondar, North west Ethiopia ( 29 ), Debere Berhan, Ethiopia ( 42 ). The disparity could be due to the perception and attitude of educated individuals toward paying for SHI. Another argument could be that people with higher levels of education are more likely to be well-paid and choose to receive medical care at private medical facilities. This study showed that government employees who have a family size greater than or equal to five were less likely to be willing to pay for the SHI scheme by 89% compared to those who had one to two family sizes. This finding is incomparable with the studies conducted in the Takusa district of northwest Ethiopia ( 43 ) and Nigeria ( 44 ). It is known that family size increases household expenses because this employee may not accept paying prorated SHI from their salary per month. Providing detailed information about SHI, especially for large family-sized households, could be important to protect all family members from the risks of illness and cover the cost of sickness treatment and medical care through a low monthly payment from their salary. In this study, the presence of chronic illness among the family members of government employees decreased their willingness to pay SHI by 63% compared to their counterparts. This finding is in line with similar studies conducted in Addis Ababa, Ethiopia ( 31 ), and North West Tigray, Ethiopia ( 45 ). Social health insurance is a mechanism of effectively pooling prepayments to the health fund regularly before any health problems occur to family members, which helps them get health care services without financial hardship when any health problems happen to them ( 46 ). Consequently, a brief discussion is needed with government employees on the advantages and disadvantages of using social health insurance, and healthcare spending paid out-of-pocket would be considerably high if family members were diagnosed with any type of chronic illness. Furthermore, government employees who do not believe in the benefit of SHI were 74% less likely to have the willingness to pay the proposed amount for SHI from their monthly salary. This study finding is nearly comparable with the studies conducted in Mekelle City, Northern Ethiopia ( 15 ), Addis Ababa, Ethiopia ( 47 ), Gondar ( 20 ), and Oskemen, East Kazakhstan ( 48 ). The possible explanation for this finding is that it is clear that individuals accept things when they have a good attitude and believe in the benefits of doing things. Despite the multitude of SHI arrangements, most employers perceive that the share of out-of-pocket spending remains unacceptably high, and they view the SHI benefits as small packages or limited services and have a negative attitude toward the health care system ( 49 ). Therefore, conducting brief discussions with government employees and providing advice through different media may increase the attitude of employees toward the SHI. The qualitative finding revealed that social health insurance implementation has an advantage for participants. As a result, the participants explained that SHI is well accepted, and has the advantage of reducing out-of-pocket payments, narrowing the inequality of services, relieving employees of high medical expenses, and providing different services for participants and their family members. This study finding is in line with a study conducted in the Philippines ( 50 ) and with other study that showed the effect of SHI on financial protection ( 51 ). Therefore, SHI implementation appears effective as it has high acceptance and is considered an appropriate program in the area to benefit the employees by reducing unexpected medical expenses. Other qualitative findings implied that currently implementing social health insurance in the study area would face challenges because there were no planned implementation documents. As a result, government employees do not know SHI service standards, health policy, or health care financing strategy. Other government employees have no trust in the services provided by public health institutions and need to launch the program in the study area. This study finding was similar to those conducted in Mekelle, Ethiopia ( 52 ), in Ghana ( 53 ) and in Africa countries ( 2 ). Therefore, providing planned and implementation documents for each sector would be enormous to bring good knowledge about SHI and provide quality service in the health care system for the client, which would minimize the challenges of willingness to join the social health insurance scheme among government employees. Strength and Limitation of the study The strength of the current study was its use of a mixed-methods approach and consideration of all government sectors, whereas the limitation was that some respondents feared expressing their feelings to data collectors during the qualitative data collection method (recording voice). Conclusion This study found that the willingness to pay for SHI was 69.90%. Factors such as the age of respondents, educational level, family size, presence of chronic illness in the family member, and belief in SHI benefits were significantly associated with willingness to pay for the proposed SHI scheme. SHI implementation has gained high acceptance and is considered an appropriate program, and providing planned and implementation documents for each sector and providing quality service in the health care system increase the willingness to join the social health insurance scheme among government employees. The Ethiopian health insurance agency should use the findings to guide regional governments in the successful implementation of the proposed SHI program. Young and highly educated people should be engaged in program development; special care should be given to employees with large family sizes; and the insurance sector should develop a plan to promote the benefits of SHI packages. Abbreviations AOR: Adjusted Odd Ratio, CI: Confidence Interval, EPHI: Ethiopian Public Health Institute, IDIs: in-depth interviews, FMoH: Federal Ministry of Health, MoH: Ministry of Health, OOP: Out of Pocket, SHI: Social Health Insurance, WHO: World Health Organization; WTP: willingness to pay Declarations Ethics approval and consent to participate All the methods used in this study were based on the Declaration of Helsinki. Ethical clearance was obtained from the Intuitional Health Research and Ethics Review Committee (IHRERC) of Haramaya University, College of Health, and Medical Sciences (IHRERC/050/2023). A support letter was obtained from the Jigjiga administration for each government organization. All study participants were informed about the purpose of the study and the benefits and risks of the study. Participants and the head of the organization were informed, and voluntarily written and signed consent was obtained before data collection. To protect the confidentiality of the information, names and identification numbers were not recorded on the questionnaire, and privacy was maintained by independently answering the questionnaire. Code was used for in-depth interviews. Consent to the publication Not applicable Availability of data and Materials All data used to analyze this study is available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding There was no fund received to write and publish this study. Authors Contributions DA and IM conceived and designed the study. DA and IM drafted the manuscript and DA was the PI of the review. DA and IM developed search strings. All reviewers (MG, AD, IM, BN, and FR) screened and selected studies. MG, AD, IM, BN, and FR extracted data and evaluated the quality of the studies. AD, IM, MG, BN, and FR performed analyses and interpretations. All authors have rigorously reviewed, read, and approved the final version of the manuscript. Acknowledgments The authors extend their deepest thanks to Haramaya University and the individuals who participated in the study: data collectors, supervisors, and administrative officials, for providing their constructive support before and during data collection. References Donfouet and Mahieu. Community-based health insurance and social capital: a review. Health economics review, 2, 1-5. 2012. Fenny AP, Yates R, Thompson R. Social health insurance schemes in Africa leave out the poor. International Health. 2018;10(1):1-3. Carrin G, James C. Social health insurance: key factors affecting the transition towards universal coverage. International Social Security Review. 2005;58(1):45-64. Purvis G, Alebachew A, Feleke W. Ethiopia health sector financing reform midterm project evaluation. Washington: USAID. 2011. Bump J, Cashin C, Chalkidou K, Evans D, González-Pier E, Guo Y, et al. 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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. Goudge J, Alaba OA, Govender V, Harris B, Nxumalo N, Chersich MF. Social health insurance contributes to universal coverage in South Africa, but generates inequities: survey among members of a government employee insurance scheme. International journal for equity in health. 2018;17(1):1-13. Gessesse AT, Berhe AA, Tilahun MG, Teklemariam TW. Factors associated with willingness to pay for social health insurance among government employees in Tigrai region, Northern Ethiopia. eajahme. 2020;4(4). Ghimire R, Wagle S. Willingness to Pay and Expected Benefits for Social Health Insurance: A Cross-sectional Study at Pokhara Metropolitan City. MedS Alliance Journal of Medicine and Medical Sciences. 2021;1(1):41-9. Amilaku EM, Fentaye FW, Mekonen AM, Bayked EM. Willingness to pay for social health insurance among public civil servants: A cross-sectional study in Dessie City Administration, North-East Ethiopia. Frontiers in Public Health. 2022;10. Darmawan KH, Satibi S, Kristina SA. PNS152 WILLINGNESS TO PAY FOR SOCIAL HEALTH INSURANCE AND RELATED FACTORS AMONG POPULATION IN YOGYAKARTA PROVINCE, INDONESIA. Value in Health. 2019;22:S787. Azhar A, Rahman MM, Arif MT. Willingness to pay for health insurance in Sarawak, Malaysia: a contingent valuation method. Bangladesh Journal of Medical Science. 2018;17(2):230-7. Mekonnen WN, Wondaferew M, Mekonen AB. Willingness to Join and Pay for Social Health Insurance Scheme Among employees in Debere Berhan Town, Ethiopia. 2019. Getahun T, Alemneh M, Amare G, Yitayal M, Feleke A. 2021. Ogundeji YK, Akomolafe B, Ohiri K, Butawa NN. Factors influencing willingness and ability to pay for social health insurance in Nigeria. PLoS One. 2019;14(8):e0220558. Weldemariam S, Damte A, Endris K, Palcon MC, Tesfay K, Berhe A, et al. Late antenatal care initiation: the case of public health centers in Ethiopia. BMC research notes. 2018;11(1):1-6. Lee HM, Ko H. The impact of benefits coverage expansion of social health insurance: Evidence from Korea. Health Policy. 2022;126(9):925-32. Tenaw Y. Analysis Of Factors Influencing Individual’s Willingness To Pay For The Compulsory Social Health Insurance Scheme: The Case Of Government School Teachers In Kolfe Keraniyo Subcity: St. Mary's University; 2017. Gulnur D. Factors influencing willingness to pay for compulsory social health insurance among informal sector workers in Kazakhstan: Graduate School of Public Health; 2020. Wang Z, Li X, Chen M, Si L. Social health insurance, healthcare utilization, and costs in middle-aged and elderly community-dwelling adults in China. International Journal for Equity in Health. 2018;17(1):17. El Omari S, Karasneh M. 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Haramaya University","correspondingAuthor":false,"prefix":"","firstName":"Mulugeta","middleName":"","lastName":"Gamachu","suffix":""},{"id":345318654,"identity":"c4998c4f-cf7b-47e7-b858-109ddd319dcd","order_by":2,"name":"Alemayehu Deressa","email":"","orcid":"","institution":"School of Public Health, College of Health and Medical Sciences, Haramaya University","correspondingAuthor":false,"prefix":"","firstName":"Alemayehu","middleName":"","lastName":"Deressa","suffix":""},{"id":345318655,"identity":"f376253c-2d96-420f-b077-297ea970c695","order_by":3,"name":"Fenan Reshid","email":"","orcid":"","institution":"School of Public Health, College of Health and Medical Sciences, Haramaya University","correspondingAuthor":false,"prefix":"","firstName":"Fenan","middleName":"","lastName":"Reshid","suffix":""},{"id":345318656,"identity":"558d7fdd-9528-4b1a-b168-30713025d896","order_by":4,"name":"Belay Negash","email":"","orcid":"","institution":"School of Public Health, College of Health and 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00:55:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4791526/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4791526/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":63351678,"identity":"c4cda1e0-4719-404d-828a-5aded9213007","added_by":"auto","created_at":"2024-08-27 08:30:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":131998,"visible":true,"origin":"","legend":"\u003cp\u003eSampling Frame of willingness to pay for SHI and associated factors among permanent government Employee in Jigjiga town of Eastern Ethiopia, 2023\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4791526/v1/493ba78ecebd2a3a3bffbb1b.png"},{"id":63351675,"identity":"deda6839-545c-43c6-b157-17c52817649e","added_by":"auto","created_at":"2024-08-27 08:30:36","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":21309,"visible":true,"origin":"","legend":"\u003cp\u003eThe professional background of a government employee in Jigjiga town, eastern Ethiopia, 2023\u003c/p\u003e\n\u003cp\u003e*Others (ICT, PAMD, Social Workers)\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4791526/v1/73df104858e291ff2323a44f.png"},{"id":63351677,"identity":"cd9c57bf-ec34-4204-9782-7f4a5a6cf260","added_by":"auto","created_at":"2024-08-27 08:30:36","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":19235,"visible":true,"origin":"","legend":"\u003cp\u003eSources of health expenditure of government employees in Jigjiga town, eastern Ethiopia, 2023\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4791526/v1/04bc285ee632488381da42d9.png"},{"id":63351674,"identity":"add05f66-f8c5-44ac-9e2c-63fb384f6ae3","added_by":"auto","created_at":"2024-08-27 08:30:35","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":52301,"visible":true,"origin":"","legend":"\u003cp\u003eThe prevalence of willingness to pay for SHI among government employee in jigjiga town, eastern Ethiopia, 2023\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-4791526/v1/b26e8f0ebe7450be3d03f73c.png"},{"id":82050238,"identity":"6848b2db-545f-4447-986a-ff7883be482b","added_by":"auto","created_at":"2025-05-06 09:53:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1731554,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4791526/v1/1e70aab0-559e-4140-8c73-f42a00ebc7fb.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Willingness to pay for social health insurance and associated factors among government employees in Jigjiga, Eastern Ethiopia: Mixed Method Study","fulltext":[{"header":"Background","content":"\u003cp\u003eSocial health insurance (SHI) increases public purchasing of health services, promoting quality and financial protection (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The SHI is a powerful mechanism for raising and pooling funds to finance health services, private health insurance, community insurance, and others in developing countries (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Enrollment in SHI is compulsory and the proposed contribution is 3% of their salary (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGlobally, 930\u0026nbsp;million people have suffered catastrophic healthcare spending and 90\u0026nbsp;million have been pushed into extreme poverty due to out-of-pocket (OOP) health expenditures. Specifically, in low and middle-income countries, 150\u0026nbsp;million people suffer a financial catastrophe each year due to out-of-pocket (OOP) health expenditures (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Low-income countries lack adequate funding for health care due to high reliance on OOP payment and development assistance (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In Ethiopia, healthcare financing is a major challenge, with 5.4% government expenditure which is below the targets set by the Abuja Declaration of 15% and 90% funded from household OOP expenditure (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSocial health insurance is important for reducing financial barriers, providing special attention to the poor community, and promoting universal health coverage and equity. It also reduces catastrophic health spending and improves access and utilization of health care, improving overall health outcomes (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). In addition, health financing reduces catastrophic health spending, improves access and utilization of health care, and improves overall health outcomes (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eImplementation of SHI is challenging in many countries due to factors such as readiness, acceptance, quality, the strength of health information systems, and awareness (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Moreover, the studies from countries reported several factors associated with willingness to pay for social health insurance such as educational status, income, history of difficulty, and other sources associated with willingness to pay (WTP) for social health insurance(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Ethiopian Federal Ministry of Health (FMOH) began healthcare financing reform in 1998 to improve and diversify resource mobilization for health and secure financial protection for citizens implementing a health insurance scheme was one of nine intervention strategies mentioned in this reform (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Furthermore, the Ethiopian government created two different types of health insurance strategies: social health insurance, which was planned to be implemented in 2014; under this strategy, active employees will be required to pay monthly premiums of 3%, while pensioners will be required to pay 1% of their monthly salary (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite the globally expanded coverage of essential health services continuing, it is not enough to meet the targets (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), and more than 32% of developing country health expenditure comes from out-of-pocket payments, which has an impact on universal health coverage (UHC), which provides access to quality essential health services (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Though few studies were conducted in Ethiopia (\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) the findings related to social health insurance and its determinants among civil servants were not well articulated, and the previous study focused on a single government organization and used only quantitative methods. In addition, SHI is not yet implemented in all regions of the country, and evidence from qualitative and quantitative studies from all government organizations was needed to predict the willingness to pay for SHI among all government employees. There was no study has been conducted in the Somali regional state about willingness to pay for social health insurance. Therefore, the current study was aimed to assess the willingness to pay for social health insurance and associated factors among government employees in Jigjiga, eastern Ethiopia.\u003c/p\u003e"},{"header":"Method and Materials","content":"\u003cp\u003e\u003cstrong\u003eStudy design, area, and period\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA mixed-methods cross-sectional study was conducted among government employees from March 30 to May 20, 2023, in Jigjiga town, Somalia, in eastern Ethiopia. Jigjiga Town is the capital city of the Somalia regional states and is located around 638 km away from the capital city of the county, Addis Ababa. According to the Ethiopian Central Statistical Agency (CSA) data for 2022, the total population of Jigjiga town was 197,966 and had 43 organizations. There are 7,158 government employees and 2236 health workers. The town had 1 referral hospital, 1 regional hospital, 1 primary hospital, four health centers, and 12 private clinics, consisting of around 2236 health workers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll Jigjiga town permanent employees who are employed by the government permanently.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion and exclusion criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThose selected government employees in Jigjiga town who had worked for the government organization for more than six months were included; however, those who had been on leave annually, sick, maternity, and studied during the study period were excluded from the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample Size\u0026nbsp;determination\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe quantitative sample size was established for both specific objectives by using a single population proportion formula, considering the proportion and factors that affect WTP for SHI among government employees.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe first objective sample size was calculated using the proportion of willingness for SHI among healthcare providers in Addis Ababa, Ethiopia (p = 0.35) (23). d = standard error or precision = 0.04; n = sample size to be calculated as follows:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cimg 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\"\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eWith the design effects of 1.5 and 10% non-response rates, the final sample size for objective one was 578.\u003c/p\u003e\n\u003cp\u003eThe sample size was\u0026nbsp;also calculated for the second objective considering factors associated with WTP for SHI from previous\u0026nbsp;(23, 24)\u0026nbsp;studies\u0026nbsp;\u0026nbsp;by Epi-Info software version 7 (stat Cal) using a two-sided confidence level ratio (unexposed to exposed) = 1. Finally, the sample size calculated for the second objective was smaller than that for the first objective.\u0026nbsp;Therefore, the sample size of the first objective is taken as the final sample size, which was 578.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative study\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor qualitative research, nine in-depth interviews were conducted among organizational leaders. During the in-depth interview, we purposely selected only one participant for each organizational government. Furthermore, sampling was guided by the emerging concerns or issues from the previous interviews.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSampling procedures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA multistage sampling method was used. There were 29 government organizations in Jigjiga town. \u0026nbsp;Considering the WHO criteria for representation from all government organizations\u0026nbsp;(25), nine government organizations \u0026nbsp;were selected by the lottery method. After selecting nine government organizations, \u0026nbsp;the proportional allocation was used to select \u0026nbsp;study participants from each government organization (health, water, general auditor, education, revenue, finance, skill and work creation, urban construction and development, and postural development bureaus) \u0026nbsp;using simple random sampling (\u003cstrong\u003eFigure\u0026nbsp;\u003c/strong\u003e1). A purposive sampling technique was employed to select participants for qualitative interviews by considering maximum variability with the assumption of obtaining rich information for an in-depth interview.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection tool and procedures\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQuantitative data were collected from government employees using a standardized self-administered questionnaire adapted from different studies\u0026nbsp;(24, 26), which has three parts (socio-demographic, healthcare-related, and health status characteristics). Data were collected by four BSc health workers supervised by two individuals after receiving two days of training on the purpose and procedure of recruiting government employees from each selected organization for this research by the principal investigator. Then an information sheet was provided for the head of the organization. After understanding the information sheet, the manager/head signed for the data to be collected. The data collectors took a questionnaire tool for participants and a volunteer-signed agreement for the data collection from each participant.\u0026nbsp;Qualitative data was collected by three trained BSc nurses using an in-depth interview guide method, a tape recorder, and field notes to address contexts, behaviors, challenges, and reflections with a daily based activity by the supervisors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData quality control\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor quantitative data, the standard questionnaire was prepared in English, translated to the local Somalia language for data collection, and then translated back into English. The data collectors were four BSC nurses selected from other health institutions and given two days of training. The questionnaire was pre-tested in another town, taking up five percent of the actual sample size. The supervisor was monitoring the completeness and consistency of the collected data along with the principal investigator on a daily basis on the spot during the data collection time. Double data entry was also done by two data clerks, and the consistency of the entered data was cross-checked. Regarding the qualitative data, an in-depth interview using an interview guide was developed in line with the objective of the study. An interview was conducted by experienced and trained data collectors. Conducting debriefing and discussion sessions each day during the entire fieldwork was encouraged to deal with any emerging issues. Facilitators\u0026rsquo; and note-takers impressions were documented for each data source. In order to ensure that the interpretation of the finding made sense, debriefing discussions with advisors, supervisors, and data collectors were conducted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOperational definition\u003c/strong\u003e\u003cstrong\u003es\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe level of WTP for SHI\u0026nbsp;\u003c/strong\u003eis\u0026nbsp;volunteer to pay for the proposed first bid (3% of monthly salary) of the premium. For those who had never heard about SHI, information was given in detail about what SHI means, its objectives, and payment-related and healthcare-related issues before asking them about their willingness to pay. One question was prepared, which was answered by yes or no\u0026nbsp;(24).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAffordable health service costs:\u0026nbsp;\u003c/strong\u003eresponses given to questions regarding the payment issue on previous illnesses asked would be yes if the participants were allowed to pay or no if they were not allowed to pay.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSatisfaction with healthcare costs\u003c/strong\u003e: the fulfilled client needs, as per the cost of healthcare or the cost of health service affordability level, to get treatment for their current illness\u0026nbsp;(27). One question would be asked about the satisfaction of clients regarding the health care cost and answered by satisfied or unsatisfied.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAwareness of SHI\u003c/strong\u003e: \u0026nbsp;the knowledge level about the SHI scheme and its importance and source of information among the individuals\u0026nbsp;(28). A question such as Have you ever heard of SHI? Was evaluated by a yes-or-no answer\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData processing and Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe quantitative data were checked for completeness and consistency by cross-checking, entered into Epi Data version 3.1, and then exported to SPSS version 22.0 for analysis. Descriptive statistics like mean and standard deviation were done and presented using frequency tables, figures, and graphs. A binary logistic regression was carried out to identify factors associated with WTP for SHI. Variables with a p-value less than 0.25 in the bi-variable logistic regression were considered for the multivariable binary logistic regression analysis to control for possible confounding factors. In the final multivariable binary logistic regression, the odds ratio along with the 95% confidence interval were used to present the association between explanatory variables and outcome variables at a p-value of less than 0.05. The goodness of model fit was checked by the Hosmer-Lemeshow statistic. Multi-collinearity tests were carried out to see the correlation between independent variables and checked by using the standard error and collinearity statistics (variance inflation factors \u0026gt; 10 and standard error \u0026gt; 2), which were considered suggestive of the existence of multi-collinearity.\u003c/p\u003e\n\u003cp\u003eQualitative data collected from audio records and field notes was transcribed in Somalia and translated into English. The translated documents were imported into Atlas. ti 7 software for analysis. Coding and categorization were done to form primary themes, both inductively and based on predetermined concepts and objectives of the study. Besides, quotes from participants\u0026rsquo; expressions that exemplify key concepts were used directly during analysis and interpretation. Finally, the result was triangulated with the quantitative results and discussions.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eSocio-demographic characteristics of respondents\u003c/h2\u003e \u003cp\u003eThis study included 578 government workers in total, with a 100% response rate. The respondents' ages varied from 20 to 49 years, with an average (+\u0026thinsp;SD) age of 34.95 (+\u0026thinsp;6.43). Males made up the majority of respondents, 414 (71.6%), and 396 (68.5%) identified as Muslims. The majority of respondents, 466 (80.6%), had a first degree, and almost half of them, 263 (45.5%), were married, and 261 (45.2%) respondents had less than two family members. 508 (87.9%) of the respondents had an average monthly income of between 5,000 and 10,000 Ethiopian birr (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The most dominant profession of the study participants was management and accounting (26.1%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic and economic characteristics of a government employee in Jigjiga town, eastern Ethiopia, 2023.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables n\u0026thinsp;=\u0026thinsp;578\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercent (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eAge categories of respondents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e38.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e167\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e28.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e414\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e71.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e28.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eReligion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMuslim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e396\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e68.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOrthodox\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e178\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProtestant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eEthnicity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSomali\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e357\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e61.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAmhara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOromo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eMarital Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e263\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e45.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e226\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e39.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDivorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eEducational level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCertificate and Diploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFirst degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e466\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e80.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMaster\u0026rsquo;s and Above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eFamily size\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e261\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e45.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e139\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e178\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePresence of under 5 years children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e329\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e249\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePresence of between 6\u0026ndash;18 years children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e301\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e52.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e277\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e47.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFamily monthly income\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;=5000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5000\u0026ndash;10000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e508\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e87.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eHealth status and health service utilization characteristics of respondents\u003c/h2\u003e \u003cp\u003eA majority of 476 (82.4%) of study respondents had no history of chronic illness. However, more than half, 324 (56.1%) of participants, reported the presence of chronic illness in their family members. Regarding the treatment-seeking behavior for the recent episode of illness, 444 (76.8%) of the study participants sought treatment. More than half, 306 (52.9%) of participants, preferred public health facilities for illness treatment. 353 (61.1%) of study participants were afforded health care costs, and about half, 287 (49.7%) of them were satisfied with the cost of health services \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e Out of the total respondents, about half (50.17%) of them had a government-sourced health expenditure (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHealth status and health service utilization characteristics of a government employee in Jigjiga town, eastern Ethiopia, 2023\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables n\u0026thinsp;=\u0026thinsp;578\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercent (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHistory of chronic illness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e476\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e82.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePresence of chronic illness among family members\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e324\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e254\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSeeking treatment for the recent episode of illness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e444\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e76.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePlace of treatment sought\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePublic health facility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e306\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e52.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrivate health facility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e193\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e33.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTraditional healer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAffordability of health care costs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAffordable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e353\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e61.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot affordable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e225\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e38.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSatisfaction with the quality of services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSatisfied\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e280\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e48.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeutral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e226\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e39.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDissatisfied\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSatisfaction with the cost of health service\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSatisfied\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e287\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e49.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeutral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e208\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDissatisfied\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eAwareness of social health insurance schemes and health care related factors\u003c/h2\u003e \u003cp\u003eNearly all 567 (98.1%) of the respondents had ever heard about SHI, and mass media 185 (32.0%) was the main source of information for SHI. Among those participants who had ever heard about social health insurance, 561 (97.1%) believed that social health insurance has benefits, and nearly half, 266 (46.0%) of participants believed that the benefit of SHI prevents unexpected health expenses. About half, 296 (51.2%) of respondents believe that SHI will create a workload on health facilities, and of them, 226 (39.1%) think they have lost interest in paying for SH (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAwareness of social health insurance schemes and health care-related factors of government employees in Jigjiga town, easteren Ethiopia, 2023.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables n\u0026thinsp;=\u0026thinsp;578\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercent (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEver heard of social health insurance scheme\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e567\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e98.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eSource of information for the SHI scheme\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMass media\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e185\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFriends\u0026rsquo; insurance agency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e172\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorking institution\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e153\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFamily\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBelieve that SHI has benefits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e561\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e97.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eBenefits of the SHI scheme\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrevent unexpected health expend\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e266\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e46.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHelp others who can't afford the\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHave timely care in times of ill\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImprove health services quality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eQuality of healthcare services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e309\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e53.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e229\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e39.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBad\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSHI will create a workload on health facilities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e296\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e282\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e48.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLost of interest in paying for SHI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e226\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e39.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eWillingness to pay for social health insurance\u003c/h2\u003e \u003cp\u003eIn this study, 404 (69.90%; 95CI: 66.15, 73.65) of study participants had a willingness to pay for the proposed SHI scheme (3% of their gross monthly salary) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eFactors associated with WTP for the proposed SHI scheme\u003c/h2\u003e \u003cp\u003eIn the final multivariable logistic regression model, the age of respondents, educational level, family size, presence of chronic illness in the family member, and belief in the SHI benefit were found to have a statistically significant association with willingness to pay for the proposed SHI scheme.\u003c/p\u003e \u003cp\u003eStudy respondents aged greater than 39 years old were 6.3 times more likely to be paid for SHI compared to those whose age was 20\u0026ndash;24 years old (AOR\u0026thinsp;=\u0026thinsp;6.30, 95% CI: 2.23\u0026ndash;17.86). Participants with the educational level of master\u0026rsquo;s and above were less likely to pay for the SHI scheme by 59% compared to those who had a certificate and diploma (AOR\u0026thinsp;=\u0026thinsp;0.41; 95% CI: 0.17\u0026ndash;0.98). Willingness to pay for SHI was decreased by 89% in participants who had a family size of five or more compared to those who had one or two family members (AOR\u0026thinsp;=\u0026thinsp;0.11, 95% CI: 0.03\u0026ndash;0.39). Participants with the presence of chronic illness in their family members were less likely to pay for SHI by 63% compared with those who do not have (AOR\u0026thinsp;=\u0026thinsp;0.37, 95% CI: 0.25\u0026ndash;0.55). Furthermore, a willingness to pay for SHI was decreased by 74% among participants who believed the SHI scheme had no benefit compared to their counterparts (AOR\u0026thinsp;=\u0026thinsp;0.26, 95% CI\u0026thinsp;=\u0026thinsp;0.08\u0026ndash;0.85) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBi-variable and multivariable logistic regression analysis of factors associated with willingness to pay to SHI among a government employee in Jigjiga town, eastern Ethiopia, 2023\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables (n\u0026thinsp;=\u0026thinsp;578)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eWillingness to pay SHI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCOR (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eAge categories in years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12(42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16(57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63(67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.52(0.64, 3.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.58(0.62,4.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64(29.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e156(70.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.82(0.82,4.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.28(0.93,5.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e35\u0026thinsp;\u0026minus;\u0026thinsp;3 9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23(33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46(66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.50(0.61,3.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.62(0.91,7.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44(26.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e123(73.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.10(0.92,4.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.30(2.23,17.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89(33.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e174(66.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66(29.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e160(70.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.24(0.44,1.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.52(0.15,1.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDivorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13(21.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48(78.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.89(0.97,3.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.91(0.41,2.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(21.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22(78.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.88(0.73,4.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.94(0.32,2.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eEducational level\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCertificate and diploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23(34.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43(65.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFirst degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e126(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e340(72.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.44(0.84,2.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.15(0.61,2.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMasters and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25(54.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21(45.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.45(0.21,0.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.41(0.17,0.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.04*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eFamily size\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70(28.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e191(73.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29(20.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e110(79.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.39(0.85,2.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.43(0.13,1.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;=5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75(42.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e103(57.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.50(0.34,0.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.11(0.03,0.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eFamily monthly income\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;=5000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28(\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42(60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5000\u0026thinsp;\u0026minus;\u0026thinsp;1000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e146(28.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e362(71.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.65(0.99,2.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.70(0.92,3.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003ePresence of chronic disease in the family members\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71(21.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e253(78.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e103(40.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e151(59.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.41(0.29,0.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.37(0.25,0.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.000**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003ePlace of treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublic health facility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100(28.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e256(71.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate health facility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68(34.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e129(65.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.74(0.51,1.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.73(0.47,1.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraditional healers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19(76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.24(0.48,3.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.87(0.65,5.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eAffordability of health care cost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAffordable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e254(71.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot affordable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75(33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e150(66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.78(0.54,1.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.90(0.59,1.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eSatisfaction with the quality of health services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSatisfied\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83(29.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e197(70.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeutral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62(27.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e164(72.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.11(0.76,1.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.27(0.81,1.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDissatisfied\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29(40.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43(59.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.62(0.37,1.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.56(0.30,1.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eEver heard about SHI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e168(29.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e399(70.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(54.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(45.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.35(0.11,1.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.78(0.18, 3.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eBelieve that SHI has benefits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e164(29.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e397(70.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10(58.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7(41.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.29(0.11,0.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.26(0.08,0.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.03*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e*p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 **p-value\u0026thinsp;\u0026lt;\u0026thinsp;=\u0026thinsp;0.001\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eQualitative findings\u003c/h2\u003e \u003cp\u003eA total of nine in-depth interviews (IDIs) were conducted, and two major themes (perceived effectiveness and challenges to implementing SHI) emerged from the thematic analysis: the perceived effectiveness theme with three subcategories (acceptability, perceived benefit, and appropriateness/reducing the risk of SHI) and challenges to implementing SHI with three subcategories (lack of knowledge of guiding principles, lack of a clear plan and implementation strategies, and poor quality health service perceptions) were identified.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003ePerceived effectiveness of SHI\u003c/h2\u003e \u003cp\u003eStudy participants explained that SHI is very welcomed, has the advantage of reducing out-of-pocket payments, narrowing the inequality of services, and is perceived as providing different services for both government employees and their family members, which relieves employees from high medical expenses. This implies that SHI implementation appears to be effective, as it has gained high acceptance and is considered an appropriate program in the area to benefit employees by reducing unexpected medical expenses (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eShows qualitative findings, from IDI from government employees in Jigjiga town, eastern Ethiopia, 2023(N\u0026thinsp;=\u0026thinsp;9 individuals across 4 female and 5 Male IDIs).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMajor themes with their sub categories on WTP of SHI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescriptions for the each categories themes (data-based)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSupportive quotations (from the interviews)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Perceived effectiveness of SHI\u003c/p\u003e \u003cp\u003e1.1. Acceptability of SHI\u003c/p\u003e \u003cp\u003e1.2. perceived benefit to SHI\u003c/p\u003e \u003cp\u003e1.3. Appropriate/essential and reducing the risk.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSHI is very welcomed and perceived as it provides different services for both government employees with their family members, which relieves employees from High medical expenses.\u003c/p\u003e \u003cp\u003eSocial health Insurance has the advantage of reducing out-of-pocket payment and narrowing the inequality in health service utilization among government employees.\u003c/p\u003e \u003cp\u003eSHI is essential to get any type of service and it can reduce the risk related to service expenses at the household level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;I am very welcome social health insurance because it provides great relief from high medical expenses for me and my entire family and enables us to use different health services (Male, 39 years old employee)\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Social Health Insurance has the advantage of reducing unexpected out-of-pocket payments and narrowing the inequality in health service utilization among government employees. Now that the cost of medical services has escalated, it also helps through premium revision, price negotiation, and standardizing the sanction process in the health system (Male, 43 years old employee)\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;We government employees should need social health insurance because it covers health-related problems at a low cost and can protect or reduce the expenses for medical services when a family member becomes ill (Male, 40 years old employee)\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Challenges to implementing the SHI\u003c/p\u003e \u003cp\u003e2.1. Lack of knowledge of guiding principles.\u003c/p\u003e \u003cp\u003e2.2. Lack of clear plan and implementation strategies\u003c/p\u003e \u003cp\u003e2.3. Poor quality health service perceptions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGovernment employees have no knowledge regarding the SHI service standards, health policy \u0026amp; health care financing strategy.\u003c/p\u003e \u003cp\u003eOverall no planned and implementation documents of SHI at the government sectors\u003c/p\u003e \u003cp\u003eGovernment employees have no trust in the services provided by public health institutions and need to launch the program in the Somalia region.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;We government employees have no knowledge regarding the presence of social health insurance structures and standards for regulating health services, and we also have no awareness regarding the availability of health policies and the health care financing strategy of social health insurance (Male, 39-years-old employee)\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Still, there is no planning and implementation documents for SHI in government sectors, and it is difficult to understand who is responsible for social health insurance implementation (Female, 39 years old employee)\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Governmental employees may not pay for social health insurance because it is a new implementation strategy in this Somali regional state, and we also have no trust in the quality of public health services because most of the time the health system sends patients to private institutions, especially for expensive services such as drugs, laboratory services, and others (Female, 37 years old employee)\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eChallenges to implementing the SHI\u003c/h2\u003e \u003cp\u003eImplementing social health insurance in the study area faced challenges, but there were no plans or implementation documents. As a result, government employees do not know the SHI service standards, health policy, or health care financing strategy. Government employees have no trust in the services provided by public health institutions and need to launch the program in the study area. This implies that to implement SHI, providing planned and implementation documents for each sector would be enormously helpful in bringing good knowledge about it and provide quality service for the client, minimizing the challenges of a willingness to join the social health insurance program (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study found that the overall magnitude of willingness to pay for social health insurance was 69.90% (CI: 66.15, 73.65%). Factors such as the age of respondents, educational level, family size, presence of chronic illness in the family member, and belief in SHI benefits were found to have a statistically significant association with willingness to pay for the proposed SHI scheme.\u003c/p\u003e \u003cp\u003eThis study revealed that the willingness to pay for SHI among permanent government employees was 69.90% which is analogous to the studies conducted in Bahir Dar City (66.6%) (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), Gondar City (62.0%) (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), and South Sudan (68.0%) (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). The study findings were higher than the previous studies conducted in Addis Ababa (28.7%) (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), Mujja town (36.6%) (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), Addis Ababa (35.4%) (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), and Gondar city (32.0%) (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). However, this finding is lower than the study done in the Harari region (89.5%) (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) and Mekelle City (85.3%) (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). This inconsistency can result from the difference in socio-demographic characteristics of study participants and the variation in study settings, time of the study, and sample size. It may also be due to the inconsistency in information dissemination, accessibility, awareness, and differences in the health and wealth status of the study participants. In our study, nearly all (98.1%) of the respondents had information about SHI. Our finding suggests that the willingness to pay for SHI may increase if the insurance sector effectively works on information dissemination and awareness creation.\u003c/p\u003e \u003cp\u003eThe study revealed that respondents older than 39 years old were 6.3 times more likely willing to pay for SHI as compared with those aged between 20\u0026ndash;24 years old. This study in line with the study done in South Africa (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) and the Tigrai region (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). This could be explained by the fact that as age increases, the probability of getting different types of chronic diseases will increase, and due to those expected chronic diseases related to ageing, study participants may prefer to pay for SHI to frequently visit health institutions for health care services. Another possible reason may be related to the fact that older individuals may have been exposed to other insurance options in their lifetime, developed a positive attitude toward their benefits, and were therefore more likely to accept and use the new system. Additionally, it has also been discovered that older people are more willing to pay for a proposed SHI scheme than younger people (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur study showed that respondents with the educational level of master\u0026rsquo;s and above were less likely to be willing to pay for the SHI scheme by 59% compared to those who had a certificate and diploma. This finding is similar to the study conducted in Dessie city, north-east Ethiopia (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e) and Mekelle city, Northern Ethiopia (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). However, this finding is in contrast with other similar studies that found that attending a higher level of education has a positive impact on willingness to pay for SHI: Yogyakarta Province, Indonesia (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e), Sarawa, Malaysia (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e), Gondar, North west Ethiopia (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), Debere Berhan, Ethiopia (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). The disparity could be due to the perception and attitude of educated individuals toward paying for SHI. Another argument could be that people with higher levels of education are more likely to be well-paid and choose to receive medical care at private medical facilities.\u003c/p\u003e \u003cp\u003eThis study showed that government employees who have a family size greater than or equal to five were less likely to be willing to pay for the SHI scheme by 89% compared to those who had one to two family sizes. This finding is incomparable with the studies conducted in the Takusa district of northwest Ethiopia (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e) and Nigeria (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). It is known that family size increases household expenses because this employee may not accept paying prorated SHI from their salary per month. Providing detailed information about SHI, especially for large family-sized households, could be important to protect all family members from the risks of illness and cover the cost of sickness treatment and medical care through a low monthly payment from their salary.\u003c/p\u003e \u003cp\u003eIn this study, the presence of chronic illness among the family members of government employees decreased their willingness to pay SHI by 63% compared to their counterparts. This finding is in line with similar studies conducted in Addis Ababa, Ethiopia (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), and North West Tigray, Ethiopia (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). Social health insurance is a mechanism of effectively pooling prepayments to the health fund regularly before any health problems occur to family members, which helps them get health care services without financial hardship when any health problems happen to them (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). Consequently, a brief discussion is needed with government employees on the advantages and disadvantages of using social health insurance, and healthcare spending paid out-of-pocket would be considerably high if family members were diagnosed with any type of chronic illness.\u003c/p\u003e \u003cp\u003eFurthermore, government employees who do not believe in the benefit of SHI were 74% less likely to have the willingness to pay the proposed amount for SHI from their monthly salary. This study finding is nearly comparable with the studies conducted in Mekelle City, Northern Ethiopia (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), Addis Ababa, Ethiopia (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e), Gondar (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), and Oskemen, East Kazakhstan (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). The possible explanation for this finding is that it is clear that individuals accept things when they have a good attitude and believe in the benefits of doing things. Despite the multitude of SHI arrangements, most employers perceive that the share of out-of-pocket spending remains unacceptably high, and they view the SHI benefits as small packages or limited services and have a negative attitude toward the health care system (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). Therefore, conducting brief discussions with government employees and providing advice through different media may increase the attitude of employees toward the SHI.\u003c/p\u003e \u003cp\u003eThe qualitative finding revealed that social health insurance implementation has an advantage for participants. As a result, the participants explained that SHI is well accepted, and has the advantage of reducing out-of-pocket payments, narrowing the inequality of services, relieving employees of high medical expenses, and providing different services for participants and their family members. This study finding is in line with a study conducted in the Philippines (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e) and with other study that showed the effect of SHI on financial protection (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). Therefore, SHI implementation appears effective as it has high acceptance and is considered an appropriate program in the area to benefit the employees by reducing unexpected medical expenses.\u003c/p\u003e \u003cp\u003eOther qualitative findings implied that currently implementing social health insurance in the study area would face challenges because there were no planned implementation documents. As a result, government employees do not know SHI service standards, health policy, or health care financing strategy. Other government employees have no trust in the services provided by public health institutions and need to launch the program in the study area. This study finding was similar to those conducted in Mekelle, Ethiopia (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e), in Ghana (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e) and in Africa countries (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Therefore, providing planned and implementation documents for each sector would be enormous to bring good knowledge about SHI and provide quality service in the health care system for the client, which would minimize the challenges of willingness to join the social health insurance scheme among government employees.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003eStrength and Limitation of the study\u003c/h2\u003e \u003cp\u003eThe strength of the current study was its use of a mixed-methods approach and consideration of all government sectors, whereas the limitation was that some respondents feared expressing their feelings to data collectors during the qualitative data collection method (recording voice).\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study found that the willingness to pay for SHI was 69.90%. Factors such as the age of respondents, educational level, family size, presence of chronic illness in the family member, and belief in SHI benefits were significantly associated with willingness to pay for the proposed SHI scheme. SHI implementation has gained high acceptance and is considered an appropriate program, and providing planned and implementation documents for each sector and providing quality service in the health care system increase the willingness to join the social health insurance scheme among government employees. The Ethiopian health insurance agency should use the findings to guide regional governments in the successful implementation of the proposed SHI program. Young and highly educated people should be engaged in program development; special care should be given to employees with large family sizes; and the insurance sector should develop a plan to promote the benefits of SHI packages.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAOR: Adjusted Odd Ratio, CI: Confidence Interval, EPHI: Ethiopian Public Health Institute, IDIs: in-depth interviews, FMoH: Federal Ministry of Health, MoH: Ministry of Health, OOP: Out of Pocket, SHI: Social Health Insurance, WHO: World Health Organization; WTP: willingness to pay\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the methods used in this study were based on the Declaration\u0026nbsp;of Helsinki. Ethical clearance was obtained from the Intuitional Health Research and Ethics Review Committee (IHRERC) of Haramaya University, College of Health, and Medical Sciences (IHRERC/050/2023). A support letter was obtained from the Jigjiga administration for each government organization. All study participants were informed about the purpose of the study and the benefits and risks of the study. Participants and the head of the organization were informed, and voluntarily written and signed consent was obtained before data collection. To protect the confidentiality of the information, names and identification numbers were not recorded on the questionnaire, and privacy was maintained by independently answering the questionnaire. Code was used for in-depth interviews.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to the publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAvailability of data and Materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;All data used to analyze this study is available from the corresponding author upon reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was no fund received to write and publish this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors Contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDA and IM conceived and designed the study. DA and IM drafted the manuscript and DA was the PI of the review. DA and IM developed search strings. All reviewers (MG, AD, IM, BN, and FR) screened and selected studies. MG, AD, IM, BN, and FR extracted data and evaluated the quality of the studies. AD, IM, MG, BN, and FR performed analyses and interpretations. All authors have rigorously reviewed, read, and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors extend their deepest thanks to Haramaya University and the individuals who participated in the study: data collectors, supervisors, and administrative officials, for providing their constructive support before and during data collection.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eDonfouet and Mahieu. Community-based health insurance and social capital: a review. 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Social health insurance, healthcare utilization, and costs in middle-aged and elderly community-dwelling adults in China. International Journal for Equity in Health. 2018;17(1):17.\u003c/li\u003e\n \u003cli\u003eEl Omari S, Karasneh M. Social health insurance in the Philippines: do the poor really benefit? Journal of Economics and Finance. 2021;45(1):171-87.\u003c/li\u003e\n \u003cli\u003eErlangga D, Suhrcke M, Ali S, Bloor K. The impact of public health insurance on health care utilisation, financial protection and health status in low- and middle-income countries: A systematic review. PLOS ONE. 2019;14(8):e0219731.\u003c/li\u003e\n \u003cli\u003eGidey MT, Gebretekle GB, Hogan ME, 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 Eff Resour Alloc. 2019;17:2.\u003c/li\u003e\n \u003cli\u003eFusheini A, Marnoch G, Gray AM. Implementation Challenges of the National Health Insurance Scheme in Selected Districts in Ghana: Evidence from the Field. International Journal of Public Administration. 2017;40(5):416-26.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Government employee, health, insurance, social security, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-4791526/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4791526/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Social Health Insurance is a system of financing and managing health care of employees. A million people suffer a health-related financial catastrophe each year, and the majority have difficulty paying health expenditures, which leads government employees to low health service utilization. However, there is no evidence of the status of health insurance in the study area. Therefore, the study aimed to assess willingness to pay for social health insurance and associated factors among government employees, in Jigjiga town, eastern Ethiopia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e: A mixed method cross-sectional study was used among 578 randomly selected government employees from March 30 to May 30, 2023, in Jigjiga city. Data was collected using a pre-tested semi-structured questionnaire through self-administration, entered into Epi-data version 3.1, and exported to SPSS version 22.0. Binary logistic regression was conducted to identify factors associated with willingness to pay. An odds ratio with a 95% confidence interval was used to interpret the finding and statistical significance was set at p \u0026lt; 0.05. Nine in-depth interviews were used to collect qualitative data, which were then analyzed thematically.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Willingness to pay for social health insurance was 69.90%. Factors such as age \u0026gt;39 years old [AOR=6.30, 95 % CI;2.23,17.86], masters and above educational [AOR=0.41, 95% CI; 0.17,0.98], family size \u0026gt;=5 [AOR=0.11, 95% CI; 0.03,0.39], chronic illness in a family [AOR=0.37, 95 % CI; 0.25,0.55], and belief social health insurance as no benefit [AOR= 0.26, 95 % CI; 0.08,0.85] were significantly associated with social health insurance. From in-depth interviews, social health insurance has high acceptance and is considered an appropriate program for the study area.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Nearly seven out of ten government employees are willing to pay for the proposed SHI. Age, educational status, family size, presence of chronic disease, and belief in SHI benefits are associated with willingness. A strong emphasis on implementation and providing necessary information for employees should be given to enhance their knowledge. It would be better to advocate the SHI for policymakers in order to start early implementation of the SHI in the Somali region.\u003c/p\u003e","manuscriptTitle":"Willingness to pay for social health insurance and associated factors among government employees in Jigjiga, Eastern Ethiopia: Mixed Method Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-27 08:30:30","doi":"10.21203/rs.3.rs-4791526/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4647d31f-813f-4ef9-8035-da63093fabf3","owner":[],"postedDate":"August 27th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":36601925,"name":"Health sciences/Anatomy"},{"id":36601926,"name":"Health sciences/Health care"},{"id":36601927,"name":"Health sciences/Health occupations"}],"tags":[],"updatedAt":"2025-05-06T09:53:46+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-27 08:30:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4791526","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4791526","identity":"rs-4791526","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}