SUPPORT OF CIVIL SERVANTS TOWARDS THE PROPOSED

SOCIAL HEALTH INSURANCE IN GULELE SUB CITY, ADDIS

ABABA, ETHIOPIA

BY: MENGISTU KIFLE

A RESEARCH REPORT TO BE SUBMITTED TO FACULTY OF PUBLIC HEALTH,

DEPARTMENT OF HEALTH SERVICES MANAGEMENT AND PLANNING,JIMMA
UNIVERSITY; IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR
MASTERS OF PUBLIC HEALTH IN HEALTH SERVICES MANAGEMENT

June 2014

JIMMA, ETHIOPIA
SUPPORT OF CIVIL SERVANTS TOWARDS THE PROPOSED SOCIAL
HEALTH INSURANCE WORKING IN GULELE SUB CITY, ADDIS ABABA,
ETHIOPIA.

BY:

Mengistu Kifle (BSC)

Name of advisors:

1. Dr Elias Ali Yesuf (MD, MPH)

2. [Link] Alaro (Bsc, MPH)

ABSTRACT

Background: The government of Ethiopia initiated social health insurance to be applied first
on formal employer with compulsory membership of the system and the members will get
health service from a health facility contracted by the Ethiopian health insurance agency by
paying a monthly premium. The support of social health insurance by all stakeholders including
civil servants will help for success and sustainability of the program. This study will provide
the prevalence of support towards the proposed social health insurance among civil servants in
Gulele sub city.

Objective: The aim of this study was to assess civil servants’ of support and its associated
factors on the proposed social health insurance scheme in Gulele sub-city.

Methods: A cross sectional study was carried out from April to June 2014 in three woredas of
Gulele sub city. A cluster sampling method was used based on available woredas in the sub
cities to select the three woredas randomly. Data on civil servants level of support towards the
proposed SHI were collected using self-administered questionnaire then entered, checked and
cleaned by EPI data version 3.1 and exported to SPSS version 20 for analysis. Descriptive,
bivariate and multivariate analyses were performed.

Result: six hundred twenty eight civil servants working in three woredas of Gulele sub city
were enrolled in this study. The overall level of support towards the proposed social health
insurance scheme in Gulele sub-city was 35.8%. Willingness to risk cross-subsidies, level of
awareness towards the scheme, preference of health facility to utilize, perceived cost and
benefit of the proposed social health insurance were influencing factors for support towards the
proposed SHI (. Those willing to cross subsidies health risks and prefer to utilize governmental
health facility were seven and five times likely to give support for the proposed social health
insurance scheme (AOR=7[2.8-16.78] and AOR=5[2.02-12.74] ) ,respectively.
Conclusion and recommendation. The study shows there was low support towards the
proposed SHI among civil servants working in Gulele sub-city. More effort should be done to
increase the support toward the proposed social health insurance among the civil servants,
which includes involvement of private health facilities as health care provider of the scheme.
.

i
ACKNOWLEDGMENT
I am most grateful to extend my deep and genuine appreciation to my advisors [Link] ALi
Yesuf and Mr. Tesfamicael Alaro , for their unreserved, concrete and valuable comment to give
life for my research project. Without them, this research paper would not be successful.
I would like to acknowledge the study participants and health care personnel who were helped
me in the data collection.
I also wish to extend my deep appreciation to my wife Medhanit Mario
It gives me a great honor to thank all my families to their moral and financial support.
Above all, my gratitude and thanks goes to the Almighty God in all respects in my life.

ii
TABLE OF CONTENT

Contents
ABSTRACT ................................................................................................................................................ i
TABLE OF CONTENT ............................................................................................................................ iii
List of Figures ........................................................................................................................................... vi
ACRONYMS AND ABBREVIATIONS ................................................................................................ vii
1. INTRODUCTION.................................................................................................................................. 1
1.1 BACK GROUND............................................................................................................................. 1
1.2 STATEMENT OF THE PROBLEM ............................................................................................... 3
2. LITRATURE REVIEW ..................................................................................................................... 4
2.1 SOCIO DEMOGRAPHIC AND ECONOMIC FACTORS............................................................. 4
2.2 WILLINGNESS TO CROSS SUBSIDIZE...................................................................................... 5
2.3 HEALTH AND HEALTH RELATED FACTORS ......................................................................... 5
2.4 PERCEIVED BENEFIT ON THE PROPOSED SOCIAL HEALTH INSURANCE SCHEME .... 5
2.5 PERCEIVED COST OF THE PROPOSED SOCIAL HEALTH INSURANCE SCHEME ........... 5
2.6 AWARENESS ON THE SOCIAL HEALTH INSURANCE SCHEMES ...................................... 6
2.4 SIGNIFICANCE OF THE STUDY ................................................................................................. 7
3. OBJECTIVE....................................................................................................................................... 8
3.1 GENERAL OBJECTIVE ................................................................................................................. 8
3.2 SPECIFIC OBJECTIVE................................................................................................................... 8
4. METHODS AND MATERIALS ....................................................................................................... 9
4.1 STUDY AREA................................................................................................................................. 9
4.2 STUDY PERIOD ............................................................................................................................. 9
4.3 STUDY DESIGN ............................................................................................................................. 9
4.4 SOURCE POPULATION ................................................................................................................ 9
4.5 STUDY POPULATION................................................................................................................... 9
4.6 INCLUSION AND EXCLUSION CRITERIA................................................................................ 9
4.7 SAMPLE SIZE DETERMINATION AND SAMPLING PROCEDURE ..................................... 10

iii
 4.7.1 SAMPLE SIZE DETERMINATION......................................................................................10
4.7.2 SAMPLING TECHNIQUE..................................................................................................... 10
4.8 VARIABLES: ................................................................................................................................11
4.8.1 DEPENDENT VARIABLE: ................................................................................................... 11
4.8.2 INDEPENDENT VARIABLES..............................................................................................11
4.9 DATA COLLECTION INSTRUMENT AND PROCEDURES........................................................11
4.10 DATA QUALITY MANAGEMENT ..........................................................................................12
4.11 DATA PROCESSING AND ANALYSIS PROCEDURE ..........................................................12
4.12 ETHICAL CONSIDERATION ................................................................................................... 12
4.13 OPERATIONAL DEFINITION .................................................................................................. 13
4.15 DISSEMINATION PLAN ........................................................................................................... 13
5. RESULT...............................................................................................................................................14
6. DISCUSSION ...................................................................................................................................... 28
LIMITATION OF THE STUDY ......................................................................................................... 30
7. CONCLUSION .................................................................................................................................... 31
8. RECOMMENDATION........................................................................................................................32
9. REFERENCES..................................................................................................................................... 33
ANNEX I QUESTIONNIARE ........................................................................................................... 37
ANNEX II AMHARIC VERSION QUESTIONNIARE ......................................................................... 43

iv
LIST OF TABLES

Table 1 Description of the background characteristics of civil servants working in Gulele sub-city
(N=628), June 2014.................................................................................................................................. 14
Table 2: Table 2: - Description of awareness level towards the proposed SHI among civil servants
working in three Gulele sub-city (N=628), June 2014 ............................................................................. 15
Table 3: Description of the perceived benefit and cost of the proposed SHI of the study participants,
Gulele sub city, June 2014 .......................................................................................................................17
Table 4: Shows the results of VAF for each dimension against each item included in the model........... 18
Table 5:Shows the component loadings for each item in the model ........................................................19
Table 6:Frequency and percentage of support towards SHI among civil servants working in Gulele sub-
city, June 2014.......................................................................................................................................... 21
Table 7:Distribution of support level among socio demographic and economic characteristic of civil
servants in Gulele sub-city June 2014 ...................................................................................................... 22
Table 8:Results of binary logistic regression for health and health related factors and respondents
support towards SHI among civil servants working in Gulele sub-city, June 2014.................................23
Table 9:Results of binary logistic regression for awareness level towards SHI and respondents support
towards SHI among civil servants working in Gulele sub-city ................................................................24
Table 10:Results of binary logistic regression for willingness to cross-subsidize and respondents support
towards SHI among civil servants working in Gulele sub-city. ...............................................................25
Table 11:Result from binary logistic regression for perceived benefit and cost of the proposed SHI
among civil servants working in Gulele sub-city, June2014.................................................................... 26
Table 12:- Results of multiple logistic regressions to identify the factors predicting the support towards
the proposed social health insurance among civil servants June 2014.....................................................27

v
List of Figures

Figure 1 Conceptual framework of the study on perception on proposed SHI and associated factors
among civil servants in Gulele sub-city ..................................................................................................... 6
Figure 2 Schematic presentation of the sampling technique for the study on perception and associated
factors associated with on the proposed SHI among civil servants working in Gulele sub-city.............. 10

vi
ACRONYMS AND ABBREVIATIONS

CBHI--Community Based Health Insurance

NHI -- National Health Insurance

OECED-- Organization for Economic Co-operation and Development

PASDEP--Plan for Accelerated and Sustained Development to End Poverty

PHI-- Provider Health Insurance

SHI-- Social Health Insurance

WHO -- World Health Organization

EHIA --Ethiopian Health Insurance Agency

vii
1. INTRODUCTION

1.1 BACK GROUND

Health care financing continues to stir debates around the world. Many low and middle-income
countries especially, keep on exploring different ways of financing their health systems. This is
because their health systems are chronically under-funded (1). User fees were initially
introduced at the point of service delivery in some of these countries in order to generate
revenue for the running of their health systems. In some contexts, the introduction of user fees
led to improvement in the quality of health care services (2). However, the overwhelming
evidence suggests that user fees constitute a strong barrier to the utilization of health care
services, as well as preventing adherence to long term treatment among poor and vulnerable
groups [1, 3]. These problems led to yet another debate to look for other alternatives of health
care financing that is social health insurance.
According to the World Health Organization, social health insurance (SHI) is a form of
financing and managing health care based on risk pooling. SHI pools both the health risks of the
people on one hand, and the contributions of individuals, households, enterprises, and the
government on the other (4).
Social Health Insurance is one of the mechanisms used to raise and pool funds for health
financing (5). The objective of Social Health Insurance is to provide healthcare that avoids large
out of pocket spending, better utilization of health services and Improve health status(6) .
The history of Social Health Insurance (SHI) is as old as the history of humankind. One of the
first countries, which institute SHI nationally, was Germany in 1883 (7). Since then the concept
of social health insurance reached throughout the world. Currently, according to World Bank,
the system is practiced in more than 60 countries all over the world (8).
Most of the developed countries took decades to have SHI implemented. Some of high-income
countries, which have successful SHI, include Germany, France, Belgium, Japan, Korea and
Switzerland. It is interesting to note that health insurance in many of these countries started
when these were classified as lower-middle income countries (9).

1
A wave of SHI initiatives has swept in developing countries across Africa, Asia, and Latin
America. In May 2005, the World Health Assembly passed a policy resolution for the World
Health Organization (WHO) whereby WHO would use SHI as the strategy for mobilizing more
resources for health, pooling risk, providing more equitable access to health care for the poor,
and delivering better quality health care. The WHO is encouraging its member states to move
ahead with SHI and will provide technical support to help nations develop (10).

A systematic review of SHI, PHI and CBHI in Africa and Asia also showed that social health
insurance improve health service utilization and provide financial protection for members in
terms of reducing their out-of-pocket expenditure (11).

2
1.2 STATEMENT OF THE PROBLEM
The principle behind Social Health Insurance is gaining popularity in developing countries and
is one of two main options towards achieving universal health coverage. However, the
development of such mechanism depends on the country’s socioeconomic background and
requires a strong political will and high administrative capabilities. Success of Social Health
Insurance also requires that considerable effort to be put into building consensus and support of
all stakeholders as well as the public and the governing body of the country (4,5,8,9,).
Social health insurance is in part about sharing responsibility and encouraging the participation
of its members. The social partners (employers, employees, government) as well as
representatives of other social groups (e.g. the informal sector, the poor), health service
providers and insurers need to agree to play their part in a new health financing system (18).
Major changes in the health sector are frequently met with resistance from interest group and
the population sometimes is skeptical about promises of improvement, thus political will as well
as a rational evaluation of the problems and opportunities are required before introducing major
health financing reform (5).

Starting from the design stage up to the implementation process of the scheme it is needed to
assess every stakeholders view and support through different tools of social dialogue including
survey for its successful implementation and sustainability(8)

Even if the scheme's design is in high gear and it is considered to be implemented in the near
future, it is not well known that civil servants support on the proposed social health insurance
and what major contextual factors influencing it much. Therefore, the purpose of this study is to
assess civil servants’ level of support and associated factor on the proposed social health
insurance.

3
2. LITRATURE REVIEW

The uncertainties of illness underpin the theory of SHI (18-20). Each year a relatively small
number of people suffer from serious illness and disability. Their medical problems can result in
large medical expenses that most people cannot afford; people will tend to seek expensive
medical services even though the costs may bankrupt patients and their families. Consequently,
most people want to be insured against such risks because they are risk averse. At the same
time, some people may not demand insurance because they believe that illness and accidents
will spare them or simply ignore the risk of potentially improvising their families such an
irrational choice could create serious social problems. Moreover, people are also selfish. If
health insurance is voluntary, young, healthy people will not want to pool their low health risk
with high-risk people (10).

2.1 SOCIO DEMOGRAPHIC AND ECONOMIC FACTORS

The country’s economic structure and development influence how many people can be covered
under social health insurance. Per captia income influences how much people can actually
contribute towards social health insurance. Higher percapita income increases the ability of the
people to contribute to SHI (17). The size of the formal and the informal sector in the country
also matters. Similar studies have cited low socioeconomic status as a significant factor for lack
of support of social health insurance. (23-24)
One study in South Africa revealed that females are more likely to support the scheme than
male (17).Another studies in India also showed that age, sex, marital status, educational level
household income has significant impact on Indian consumers’ perception towards health
insurance (24)
Respondents with age of 45 and above have higher positive attitude towards health insurance
compared with age group of below 45 years of age. Regarding sex, male respondents’ attitude
mean is higher than female respondents are. In the case of marital status, widowed has a higher
attitude mean and but divorced has least mean score of positive attitude (25).

4
2.2 WILLINGNESS TO CROSS SUBSIDIZE
A social health insurance scheme may be more appropriate for a country with larger number of
formal sector employees or with a strong sense of national solidarity among eligible members
(26). Because public acceptance of SHI is strongly related to the extent to which the population
is acquainted with the notion of risk and income cross-subsidies and supports these cross-
subsidies (27)

2.3 HEALTH AND HEALTH RELATED FACTORS

A descriptive study in south Africa to assesses the level of support for a compulsory
contribution towards a hospital insurance scheme funding care at public sector hospitals showed
that the government employed support was almost unanimous; 87 per central if public
hospitals were improved . The results also showed that only 11 per cent of employees supported
an SHI scheme if public hospitals remain as they are (17).Another study in South Africa
revealed that quality of health service at public health care facilities prerequisite for the
acceptance of the proposed social health insurance (28). In India, also customer perception
towards health service providers of health insurance found to be factor for their decision of
purchasing. (29)

2.4 PERCEIVED BENEFIT ON THE PROPOSED SOCIAL HEALTH INSURANCE

SCHEME
A big part in determining whether a SHI is technically feasible, financially viable and
supported by all stakeholders depends on the depth and height of coverage i.e. range of benefit
available. (30) In line with this other study conducted among house hold in Nigeria revealed
that the odds of enrollment and support towards SHI was 1.8 times among those perceive
beneficial. (22)

2.5 PERCEIVED COST OF THE PROPOSED SOCIAL HEALTH INSURANCE

SCHEME
The formal sector may view health insurance contributions as a direct negative impact on profits
or incomes and may have less support toward SHI (32). Other study done in Nigeria showed
that the perceived cost of the respondent was barrier to support and enroll of NHI in the country
(22)

5
2.6 AWARENESS ON THE SOCIAL HEALTH INSURANCE SCHEMES
Research done in India showed that the awareness of health insurance significantly affects the
attitude on health insurance (33). Studies in Uganda also found out that there was limited
knowledge about the proposed social health insurance scheme and unfavorable attitude towards
the social health insurance schemes (34-36). Another study in Nigeria showed that there is a
significant association exists between willingness to participate in NHIS scheme and awareness
of methods of options of health care financing (37). Study done in Malaysia revealed
Respondents with good knowledge on NHI is 3.4 times likely to support NHI than a respondent
with poor knowledge (38).

Figure 1 Conceptual framework of support towards the proposed SHI and associated
factors among civil servants after reviewing literature in Gulele sub-city

6
2.4 SIGNIFICANCE OF THE STUDY
This study can be used as one tool for social dialogue to assess civil servants level of support on
the proposed SHI scheme. Civil servants are primary stakeholders in the implementation of the
scheme, so determining their level of support and its' associated factors is very essential for
smooth implementation and success of the scheme.

This study also can be used to understand the level of awareness on the proposed SHI among
civil servants and identify the gap, which helps to develop evidence based communication
strategy.

Civil servants can use this survey to show their voice and concerns for other responsible bodies.

The result of the study will be used for policy makers, Ethiopian health insurance agency, and
different concerned bodies and researchers

7
3. OBJECTIVE

3.1 GENERAL OBJECTIVE

To assess civil servants support and its associated factors towards the proposed social health
insurance in Gulele sub-city, Addis Ababa

3.2 SPECIFIC OBJECTIVE

 To measure the prevalence of support towards the proposed social health insurance
scheme among civil servants in Gulele subs city.

 To determine factors associated with governmental employee’s support towards the

proposed social health insurance schemes.

8
4. METHODS AND MATERIALS

4.1 STUDY AREA AND PERIOD

The study was conducted in three woredas of Gulele sub city, which is one of the ten sub cities
in Addis Ababa. The district is located in northern suburb of the city, near the Mount Entoto and
Entoto Natural Park covering 30.18 km2 (11.65 sq mi) and it borders with the districts of Kolfe
Keranio, Addis Ketema, Arada and Yeka. Based on central statistics agency report of 2007, the
2011-projected total population was 248,865. The woredas in the sub-city in which the study
conducted were Woreda 2,Woreda 4 ,Woreda [Link] to the woredas human resource
offices the number of total employee working in the three woredas during study period were
[Link] total employee working in the selected woredas,702 of them had 6 months above
work experience. Within selected woredas, there are governmental health centers, governmental
school and woreda administration administered by each the sub city and each woredas. The
woreda administration comprises 13 different offices..

4.2 STUDY PERIOD

The study was conducted from April 2014 to June 2014.

4.3 STUDY DESIGN

Facility based Cross-sectional study design was used.

4.4 SOURCE POPULATION

All governmental employees who are working in governmental organizations administrated by
Gulele sub-city

4.5 STUDY POPULATION

Governmental employees working in Governmental organizations in the Sampled wordas of
Gulele Sub city and fulfill the inclusion criteria

4.6 INCLUSION AND EXCLUSION CRITERIA

Governmental employees with work experience of six or more months in the sub city during
study periods

9
4.7 SAMPLE SIZE DETERMINATION AND SAMPLING PROCEDURE

4.7.1 SAMPLE SIZE DETERMINATION

4.7.2 SAMPLING TECHNIQUE

Cluster random sampling technique has been used. Since there is the same governmental
organization in the ten Woredas, ten clusters formed based on the woredas. Three wordas were
selected randomly from ten woredas then all governmental employees in the three woredas were
included in the study

Gulele sub city

W W W W W W W W W W

1 2 3 4 5 6 7 8 9 10

W W W

2 4 8

628
Figure 2 Schematic presentation of the sampling technique for the study on support and its
associated factors towards the proposed SHI among civil servants working in Gulele sub-city.

10
 4.8 VARIABLES:

4.8.1 DEPENDENT VARIABLE:

Prevalence of support toward the proposed social health insurance scheme

4.8.2 INDEPENDENT VARIABLES

[Link] demographic and economic factors; age, sex, marital status, level of education, and
income, working organization/office
II. Health and health related factors; Perceived health status of the family, Chronic disease
patient in the family, preference of health care facility for utilization and, and the presence
of health care free of cost and money to get for health care.
III. Willingness to cross subsidizes others; Willingness to income cross-subsidize and
Willingness to cross-subsidize health risk.
IV. Awareness on proposed social health insurance
V. Perception on SHI; perceived benefit and cost toward SHI

4.9 DATA COLLECTION INSTRUMENT AND PROCEDURES

Data was collected through a structured, pretested self-administered questionnaire. The

questionnaire has five parts which assess back ground information, awareness towards
social health insurance scheme, health and health related conditions, willingness to cross
subsidize others and perception towards social health insurance in related to perceived
benefit and cost of SHI and support for the proposed SHI . The data collection tool adapted
from similar survey reviews in other countries (17, 22, and 28). Three data collection
facilitators who were diploma nurses and one-degree holder supervisor were recruited for
questionnaire administration and supervision, respectively. Orientation was given for data
collection facilitators and supervisor, both before and after the pretest. Prior to data
collection, a pretest was conducted to ensure clarity of questions. The result of the pretest
was discussed, and some correction and changes like: Ambiguous questions, logic and skip
pattern was revised before the questionnaire finalized.

11
4.10 DATA QUALITY MANAGEMENT
To maintain the data quality: Questionnaires was prepared first in English then translated to
Amharic and then back to English by another person in order to ensure consistency. Pretest was
done on 5% of the sample in Kolfe Keranio that have similar back ground one week prior to the
data collection and amendment was made accordingly for the instrument. The facilitators and
Supervisor was oriented before and after pretest and Feedback from the supervisor and
facilitators was incorporated to enrich the questionnaire and make more applicable to the local
situations. The questionnaire was administered at the governmental organizations by oriented
diploma holder nurses that have prior experience of data collection. Unclear and ambiguous
matters were clarified for the participants. The PI and supervisors checked each questionnaire
daily.

4.11 DATA PROCESSING AND ANALYSIS PROCEDURE

After categorization and coding was done, double entry verification using Epidata version 3.1
used to enter, clean and edit the data, finally it was exported to SPSS version 20 for analysis.
Frequency distributions with its percentile were used to organize the data, to see the distribution
and present the responses obtained. Measures of central tendency was calculated and utilized for
appropriate variables to describe the data. Bivariate logistic analysis was employed and those
variables having a p value ≤ 0.25 was identified as a candidate for multivariate logistic analysis.
Variables was selected into the model by Back ward step wise method Fitness of the model and
multicollinerity between the independent variables was assessed .Variables having a p value less
than 0.05 was considered as significantly associated with Support for SHI in multivariate
logistic regression. Adjusted odds ratio with its confidence interval was used to see strength of
association. For the questions, which were designed to address perceptions of the study
participants about the benefit and cost of social health insurance, a categorical or nonlinear
principal component analysis was conducted and based on eigenvalues percentage of variance
accounted for each dimension was calculated.

4.12 ETHICAL CONSIDERATION

Before the data collection, ethical clearance letter was obtained from ethical review committee
of JU College of public health and medical sciences. The respondents were informed about the

12
purpose of the study, and their oral consent was obtained. The respondents’ right to refuse or
withdraw from participating in the interview was fully maintained and the information provided
by each respondent was kept strictly confidential

4.13 OPERATIONAL DEFINITION

 support of SHI is whether civil servants agree with the establishment of social health
insurance in Ethiopia measured on a likert scale (strongly oppose, oppose, neutral,
support and strongly support)
 Do not support the proposed SHI: - if individuals strongly oppose or oppose for
establishment of social health insurance in Ethiopia measured by a liker scale (17)
 Perceived benefit:-summated response of civil servants for 13 likert items on the
benefit of the proposed social health insurance
 Perceived cost:-it refers to summated response of civil servants for five liker items on
the cost of the proposed social health insurance.
 Well Aware:- civil servants responded 5 and above correctly from nine questions
associated with awareness on SHI (38)
 Not well aware:- civil servants responded four and below from nine questions
associated with awareness on SHI( 38)
 Willing to risk cross-subsidies: -Civil servants agreed for the statement :I would be
willing to pay the same amount of money each month as everyone else ,even though
others who are more sick than I am will use the service more than me (28)
 Willing to income cross-subsidies:-those individuals give support for the question: Do
you support the contribution of individuals for health care increases with wealth? (28)

4.15 DISSEMINATION PLAN

The result of the study will be communicated to Jimma University college of Public Health and
Medical Sciences Graduate School, Ethiopian Social health insurance Agency and to concerned
bodies in the study area. Finally, an effort also will be made to publish in a local or international
journal.

13
5. RESULT

5.1. Socio-demographic characteristics of the study subjects

A total of 628 government employees with response rate of 71.04% at different offices in
Gulele sub-city were included in this study. About 355 (56.5%) of the participants were female.
The mean age of the participants was 29 years with a standard deviation of 6.8 years, (Table1).

Most of the study participants, 513 (82%) were Orthodox Christians followed by Protestants, 72
(11.5%) and the rest were Muslims and Catholic followers. Regarding marital status of the
respondents, majority, 395(63.1%) were single, about a quarter, 170(27.2%) were married, and
and the rest were divorced and widowed, 35(5.6%), 26(4.2 %), respectively.

Regarding educational status, 333 (53.4%) of the respondents had diploma followed by those
holding degree and above, 200(32.1%); the rest were 4-12 grades and certificate holders,
38(6.1%), 51(8.2%), respectively. Of the respondents, 323 (51.4%) were from woreda
administration, 211(33.6%) were form health center, and 94 (15%) from school.

Table 1 Description of the background characteristics of civil servants working in Gulele sub-
city (N=628), June 2014.

Variable Mean [Link] Min Max

Age(years) 29 6.8 18 57
Work experience 5 6 .5 34
House hold size 3 2.3 1 13
size
Income 1652 671 359 5373

14
5.2. Participants Level of Awareness on the proposed social health insurance scheme

All of the respondents heard about the proposed SHI and 240(38.2%) of the respondents heard
about the proposed SHI for the first time from governmental officials. Television was the
second most frequent, 171(27.2%) source and colleagues was the third most frequent source
accounting for 124(19.7%).Other sources of information include: Radio 34(9.6%) and news
paper 27(4.3%). Most of the respondents were unaware of the eligible contributor for the
scheme 409 (69.1%), health services not covered by SHI 392 (64.4%) and eligible health care
provider to provide health care for beneficiary of the scheme 509(86.9%). Whereas most of
respondents had a better awareness level regarding the amount of premium, 422(71.5%),
frequency of contribution, 449(75.5%) and beneficiary of SHI, 368(59.0%) (Table 2).

Table 2: Table 2: - Description of awareness level towards the proposed SHI among civil
servants working in three Gulele sub-city (N=628), June 2014

Variable Well Not well Aware (%)

Aware(%)
Awareness on contributor for SHI 183(30.9%) 409(69.1%)
Awareness on health service not covered by 217(35.6%) 392(64.4%)
SHI
77(13.1%) 509(86.9%)
Awareness on health care providers for SHI

Awareness on the amount of premium of SHI 422(71.5%) 168(28.5%)

Awareness on the frequency of contribution for 449(75.5%) 144(24.3%)
SHI
Awareness of contribution by gov. for SHI 293(50.6%) 286(49.4%)
Awareness on the beneficiary of SHI 368(59.0%) 256(41.8%)
258(41.3%)
Awareness on Benefit package of SHI 366(58.7%)
310(49.7%)

15
Over all Awareness on co-payment for SHI 314(50.3%)

5.3 Health and health related conditions

The respondents rate their family’s health status as poor 80 (12.8 %), medium 148(23.7%) and
good 397(63.5%). Of the respondents, (35) 11.1% of them stated there is a patient with chronic
disease who needs continuous follow up in their family.

Regarding utilization of health facility, most of the respondents choose to use private health
facilities, 408(65.38%) (Private clinics, 42.4%, private hospitals, 11.7 %) and 209(33.4%) of
them utilize public health facilities mostly (health centers, 243 (38.9%), Governmental hospital
28(4.5%)). The remaining 8 (1.3%) went to spiritual places and traditional healer.

The reasons respondents put for their preference of utilization in private health facility were
being clinical effective 168(42.4%), less crowdedness 102(25.8%), near for house hold
78(19.7%) , and service given with courtesy 26(6.6%)

On the other hand, of the reasons of respondents who usually utilize government health facility
for health care need, 108(52.9%) of them were because of its cheapness for medical bill in
addition to its nearness from house hold 62(30.4%).

Regarding money to get for health care, Most of respondents 425 (69.0%) replied as it was
difficult to get money for medical treatment compared to those no having difficulty to get
money for health care 191(31.0%).

5.4 Willingness to cross subsidize

16
 In general, the respondents do not appear to be well acquainted with, nor are generally
supportive of, the notion of risk crosses subsidization. Only 218(35.2%) of all respondents
agreed with the statement : I would be willing to pay the same amount of money for each
month as everyone else, even though others who are more sick than I am will use the services
more .In line this only 227(36.1%) of the respondents support for financial cross -subsidization

5.5 Perceived benefit and cost of the proposed social health insurance

For the questions, which were designed to address perception of the study participants on
benefits and costs of social health insurance, a categorical or nonlinear principal component
analysis was conducted. The following are the outputs of the analysis.

Over all 18 items has been used to measure the perceived benefit and perceived cost towards the
proposed social health insurance among study participants in the woredas.

Table 3: Description of the perceived benefit and cost of the proposed SHI of the study
participants, Gulele sub city, June 2014

Variables Categories and their frequencies

Very Disagree Neutral Agree Very

disagree agree
Perceived benefit toward SHI
Benefits in reduction of medical bills 103 105 94 229 52

Prevents borrowing for ill health

95 124 110 191 65
Prevents unexpected expense 90 111 238 81
62
Increases access for health care 85 113 242 80
63
Increases equity for health care 88 127 239 71
55
Increases health care utilization 109 102 243 66
61
Enhances solidarity 106 110 249 55
62
Increases quality of care 107 107 251 56
61

17
limit choice of professionals Health 139 162 162 37
care providers 80
Not benefit since governed by gov’t 93 104 230 72
82
SHI is not beneficial since it is not 98 98 236 70
comprehensive for family 79
SHI not covers most of the family 109 101 247 51
73
SHI not benefits me 79 95 229 91
85
Perceived cost toward SHI
Premium low compared to benefit 173 88 125 59 134

Copayment is low 57 230 110

130 51
Premium high compared to salary 73 197 158 111
38
Government contributes less for SHI 93 110 205 123
50
We should not pay for SHI 139 91 167 125
57

The first dimension accounts for 47.205 % of the variance in the optimally scaled matrix of 13
items. The second dimension accounts for 11.826 % of the variance while the total model (two
dimensions) accounts for 59.031 % of the variance in the optimally scaled items.

The variance accounted for table displays the coordinates for each item on each dimension in
relation to the centroid (0, 0) and when all the items are represented by a straight line between
dimension 1 (x-axis) and dimension 2 (y-axis). In the current list of items the mean coordinates
are not close to or below 0.10 and therefore all the items are contributing to the principal
componen.

Table 4: Shows the results of VAF for each dimension against each item included in the model

Items Centroid Coordinates Total (Vector Coordinates)

Dimension Mean Dimension Total
1 2 1 2
Benefits in reduction of medical bills .516 .025 .270 .515 .000 .515
Prevents borrowing for ill health .378 .050 .214 .378 .002 .380
Prevents unexpected expense .574 .058 .316 .569 .021 .590

18
Increases access for health care .672 .064 .368 .671 .001 .671
Increases equity for health care .681 .083 .382 .679 .028 .707
Increases health care utilization .668 .083 .376 .665 .027 .693
Enhances solidarity .680 .097 .389 .675 .025 .700
Increases quality of care .670 .088 .379 .666 .019 .685
Limit choice of health care providers .535 .126 .330 .528 .060 .588
Not helpful since governed by gov’t .640 .091 .365 .636 .042 .679
Social health insurance benefit is not .614 .110 .362 .609 .045 .654
Comprehensive
SHI doesn't covers most of the family .643 .097 .370 .640 .029 .669
SHI will not benefits me .654 .097 .375 .648 .036 .684
Premium low compared to benefit .248 .335 .292 .215 .330 .546
Copayment is not high .359 .359 .359 .300 .339 .639
Premium high compared to salary .262 .415 .339 .221 .401 .622
Government contributes less for SHI .172 .415 .294 .126 .411 .538
We should not pay for SHI .243 .450 .347 .228 .428 .657
Active Total 9.208 3.044 6.126 8.969 2.247 11.216
Component Loadings

Component Loadings, shows the coordinates for each item on each dimension; which are
plotted in the next element of the output. Here, we can see how the items are related to one
another and to the two dimensions. We can see that the first thirteen items tend to coalesce
together in the upper range of both dimension 1 and dimension 2; whereas the other five items
tend to coalesce at the lower range of dimension 1 and they tend to vary substantially along
dimension 2. From this table we can easily figure out which items belong to the same group.

Table 5:Shows the component loadings for each item in the model

Items Dimension
1 2
Benefits in reduction of medical bills .717 .008

19
Prevents borrowing for ill health .614 -.047
Prevents unexpected expense .754 .147
Increases access for health care .819 .027
Increases equity for health care .824 .167
Increases health care utilization .816 .165
Enhances solidarity .822 .159
Limit choice of health care providers .816 .138
Not helpful since governed by gov’t .727 .246
Social health insurance benefit is not .798 .206
Comprehensive
SHI doesn't covers most of the family .781 .212
SHI will not benefits me .800 .172
SHI benefits me .805 .190
Premium low compared to benefit -.464 .575
Copayment is not high -.548 .582
Premium high compared to salary -.470 .633
Government contributes less for SHI -.356 .641
We should not pay for SHI -.478 .654

Therefore, we can finally conclude that based on their VAF, all of the items have contribution
for the principal components and because of that no item is going to be dropped for perceived
benefit and perceived cost of SHI Finally, for each group summated score has done.

5.5.1Perceived benefit of the proposed social health insurance

The mean score on perceived benefit of the proposed social health insurance among
respondents was 39.6 with standard deviation of 13.78 .The scores ranges with minimum value
of 8 up to maximum value of 64.

5.5.2 Perceived cost of the proposed social health insurance

20
The mean score of the respondents for scale, which measures the cost of the proposed social
health insurance, was 15.4 with standard deviation of 5.9. The score values range from 4 up to
25.

5.6 Support toward the proposed social health insurance

Regarding the support of study participants, of 628 respondents who participated in this study,
only 201(34.3%) of the respondent, gave support for the start of the program while 385 (65.7%)
of the respondents oppose it. Results are shown in table (6)

Table 6:Frequency and percentage of support towards SHI among civil servants working in
Gulele sub-city, June 2014.

Support toward SHI Frequency Percent

Strongly oppose 108 17 %
Oppose 279 44.4%
Neutral 41 6.5%
Support 166 26.4%
Strongly Support 34 5.4%
Total 628 100%

5.7 Distribution of support level toward the proposed SHI and socio-demographic
characteristics of the respondent

From married civil servants, only 40(25.5%) of the respondent did gave their support for the
proposed social health insurance.

21
Table 7:Distribution of support level among socio demographic and economic characteristic of
civil servants in Gulele sub-city June 2014

Socio Categories Support for SHI Crude P-

economic value
Demographic Not Support No OR%
Variables Support No (%)
(%)

Sex
Male 170(65.9%) 88(34.1%) 1
Female 215(65.5%) 113(34.5%) 1.102 0.931
Marital status 0.001*
Married 118(74.7% ) 40( 25.3% ) 1
Single 233(63.0% 137(37.0%) 1.7 0.009
Divorced 20(60.5%) 13(39.5%) 1.9 0.104
Widowed 12(52.2%) 11(47.8%) 2.7 0.029
Religion 0.437
Orthodox 309(64.4%) 171(35.6%) 1
Protestant 52(75.4%) 17(24.6%) 0.68 0.55
Muslims 17(63.0%) 10(37.0%) 0.44 0.33
Catholic 6(75%) 2(25%) 0.72 0.59
Other 1(50%) 1(50%) 0.5 0.33
Educational 0.27
level
Four up to 12 grades 19(54.3%) 16(45.7%) 1
Certificate 25(53.2%) 22(46.8%) 0.92 1.04
Diploma 223(71.5%) 89(28.5%) 0.44 1.19
Occupation 0.5
Executive administrator 25(67.6%) 12(32.4%) 1
Professional 283(68.5%) 130(31.5%) .95 0.91
Technical support 20(58.8%) 14(41.2%) 1.46 0.45

Clerical and
28(56.0%) 22(44.0%) 1.6 0.27
administrative
Service occupation 27(62.8%) 16(37.2%) 1.23 0.65
Operator or laborer 2(50%) 2(50%) 2.1 0.48
Work 0.001
organization
Woreda administration 172(57.00%) 130(43.00%) 1
0.48
School 55(61.10%) 35(38.9%) .84
.30 0.001
Health center 158(81.4%) 36(18.6%)

*p-value less than or equal to 2. 5

22
5.8Health and health related factors and support towards SHI

Regarding health and health related factors, support for the proposed social health insurance
was as follows:- among civil servants who had health care service in their family were
49(21.8%);those who had poor, medium ,good health status 55.0%,25% and 36% respectively;
those who prefer to utilize private and government health facilities 27.2% and 43.7%
respectively; and those who had difficulty to get money for health care were 26.8% (Table 9)
All mentioned health and health related factors were candidate for multivariate logistic
regression analysis except presence of chronic patient in the family (table8)

Table 8:Results of binary logistic regression for health and health related factors and
respondents support towards SHI among civil servants working in Gulele sub-city, June 2014.
Health and Categories Do not support SHI Crude OR P-value
related conditions support SHI Frequency
Frequency (percentage)
(percentage)
The presence of health
care for free

No 208(58.3%) 149(41.7%) 1
Yes 176(78.2%) 49(21.8%) 0.223 0.001*
Health status of family 0.001*
Poor 1
Medium 51(75%) 17(25%) 0.49 0.02
Good 119(64%) 67(36.0%) 0.69 0.16
preference of health
facility 0.001*
Private 241(72.8%) 90(27.2%) 1
Government 138(56.3%) 107(43.7%) 4.58 0
Others 6(75%) 2(25%) 1.207 0.89
Money to get for health
care 0.001*
not difficult 131(73.2%) 48(26.8%) 1
difficult 246(62.3%) 149(37.7%) 0.06

Chronic disease No 321(65%) 166(34.1%) 1

23
 Yes 39(62.9%) 23(37.1%) 87 .42

*p-value less than or equal to .25

5.9. Respondent’s awareness on SHI and support towards SHI

Among respondents who had been well aware on the proposed social health insurance,51.9% of
them support the proposed social health insurance while from those not well aware about the
proposed social health insurance only 24% of them support the proposed SHI (table 9).The
awareness level of individuals was candidate for multivariate logistic regression.

Table 9:Results of binary logistic regression for awareness level towards SHI and respondents
support towards SHI among civil servants working in Gulele sub-city
Awareness Categories Do not support support SHI Crude P-
level SHI Frequency OR value
Frequency (percentage) (percentage)

not aware
Awareness well 283(75.3%) 93(24%) 1
Aware well 99(48.3%) 107(51.9%) 3.2 0.001*
*p-value less than or equal to .25

5.10Willingness to cross-subsidize and support towards SHI in related to the support of

the program.

Regarding respondents willingness to cross-subsidize, from those willing to share the health
risk of others 60.4% of them gave their support for the proposed SHI .In addition from those

24
 who support of financial cross-subsidization 51% of them gave their agreement for the start of
the proposed social health insurance.

Table 10: Results of binary logistic regression for willingness to cross-subsidize and
respondents support towards SHI among civil servants working in Gulele sub-city.

Willingness Categories Do not support SHI Crude P-

support SHI OR value
To cross-subsidize Frequency

Frequency (percentage)
(percentage)

Risk cross-
subsidization Not volunteer 307(77.7%) 88(22.3%) 1

volunteer 74(39.6%) 113(60.4%) 5.32 .0001*

Financial cross-
subsidization Not support 283(74.9%) 95(25.1%) 1

Support 102(49%) 106(51%) 3 .0001*

*p-value less than or equal to .25

25
5.11 Perceived cost and benefit towards the proposed social health insurance.

Result from bivariate analysis shows perceived cost and benefit of the respondents towards
proposed social health insurance was candidate for multivariate regression ( table 11).

Table 11:Result from binary logistic regression for perceived benefit and cost of the proposed
SHI among civil servants working in Gulele sub-city, June2014.

B S.E. Wald Sig. Exp(B) 95% [Link]

EXP(B)
Lower Upper
Perceived Cost -.21 .029 76.878 .000 .79 .735 .823
Perceived Benefit .503 .049 105.161 .000 1.654 1.502 1.821

5.12 Multiple logistic regressions

After conducting binary logistic regressions ,the candidate variables selected for multivariate
analysis were; marital status, work organization, perceived cost and benefit towards SHI, the
presence of health service for free, awareness level of SHI, preference of health facility for
care, money to get for health care willingness to cross subsidize risk and finance and health
status of family. Multiple logistic regressions were conducted to identify the association
between the independent and the dependent variables. A cut off point of 0.05 was used to retain
the variables in the final model. Table 12 summarizes the significant predictors of perception in
related to support of the program. The results are summarized as adjusted odds ratio with their
95% confidence interval.

26
 On multiple logistic regressions, the multivariate result showed that those who had well
awareness on the proposed SHI were 2.5 times more likely to support the start of the proposed
social health insurance than those had less awareness (OR=2.5[1.04-5.9] ) ,those willing for risk
cross-subsidization were 7 times more likely to support the proposed SHI than those not
willing(OR=7[2.8-16.78]. In this study Civil servants who prefer to utilize government health
facilities mostly (health center & hospitals) to utilize during illness were 5 times more likely to
support the proposed social health insurance (OR=5[2.02-12.74]).

For every one-unit increase in perceived cost score of the proposed social health insurance
among civil servants, will decrease the probability of support for the proposed social health
insurance in .[Link] perceived benefit ,this study revealed that in every one unite
increase in perceived benefit score increase the probability of support for the proposed social
health insurance scheme.

Table 12:- Results of multiple logistic regressions to identify the factors predicting the support
towards the proposed social health insurance among civil servants June 2014.

Variables Categories B Adjusted OR [95% CI] P-value

Perceived cost of SHI -.25 .78 [.74-.82] 0.001*

Perceived benefit of SHI 0.5 1.6[1.44-1.88] 0.001*

Preference of health care to Private health 1 .002*
utilize facility
Government Health 5[2.02-12.74] .001*
facility
Other s 6[.52-78.37] .148
Risk cross subsidization Willing to cross- 7[2.8-16.78] 0.00*
subside
Awareness of SHI Well Aware SHI 2.5[1.04-5.9] .04*

*- pvalue<0.05, Hosmer and Lemeshow test X2=6.116 and p value 0.295, Negelkerke R2=0.420

27
6. DISCUSSION

Prior to implementing major health reform, it is important to assess the support of the public. In
this study, Out of 628 respondents only 35.8% of them support the start of the program which
is Consistent with other study which was 35% (1)where as lower than other studies done in
Kenya, South Africa and Malaysia 93%, 53% and 71.2% respectively(34,39,17). The difference
may be due to the studies conducted in other countries were where health insurance is more
prevalent and a lot done to increase awareness and build consensus during design stage.

In this study, Level of support was almost five times higher among those who prefer and utilize
government health facility mostly compared to those prefer private health facility
(AOR=5.386(2.8-16.78)).

This is may be most of the respondents believe that health providers which contract with the
SHI scheme would be government health facility as evidenced by 332(86.6%) of respondent
answer that the health service would be given by only government health facilities.

In line with this, study from South Africa revealed that only 11% of employee support SHI
scheme if public health facility remain, as they are (39)

Public acceptance of SHI is strongly related to the extent to which the population is acquainted
with the notion of risk and income cross-subsidies and supports these cross-subsidies (28)

28
This study revealed also, respondents willing to cross-subsidies health risk of others were
approximately three times more likely to support the proposed social health insurance scheme
(AOD=2.8[1.9- 4.42]. However, In this study, Only 218(35.2%) of all respondents agreed with
the statement : I would be willing to pay the same amount of money for each month as
everyone else, even though others who are more sick than I am will use the services more .In
addition, only 227(36.1%) of the respondents support for income cross subsidies

A big part in determining whether a SHI is technically feasible, financially viable and
supported by all stakeholders depends on the depth and height of coverage i.e. range of benefit
available and the cost (30).. In this study also support toward the proposed social health
insurance found to be significant predictor of perceived benefit of the scheme as evidenced by
for one unit increase in perception score of benefit, the odds of support increases in 1.6. In line
with this, other study conducted among household in Nigeria revealed that the odds of
enrollment and support towards SHI was 1.8 times among those perceive beneficial (22).

Regarding perceived cost of the proposed SHI, this survey demonstrates ;the perceived cost of
the proposed SHI by civil servants were predictor for the level of support towards the scheme(
for every one unit increment of perception score of cost on SHI , the odds of support toward the
proposed social health insurance will decrease by 22%. This is consistent with other study done
in Nigeria, which showed that the perceived cost of the respondent was significant for barrier or
support of NHI in the country (22)

Education and promotion is important before implementing major policies. It gives the public
an understanding of why such policies were introduced, how such policies intend to serve the
public and what are the potential benefits. This study shows that awareness is a predicting factor
on respondent’s support towards SHI with OR of 2.5 at 95.0% CI of 1.04-5.9. In other words:
Respondent with well awareness on SHI is 2.5 times likely to support NHI than a respondent
with poor awareness. Similarly, study done in Malaysia showed Respondents with good
knowledge on NHI were 3.4 times likely to support NHI than respondents with poor
knowledge(17).

29
LIMITATION OF THE STUDY
This study was limited by the fact that it uses likert items to measure the dependent variable and
perceived cost and benefit of the proposed SHI, which can lead to biases; Central tendency bias
Acquiescence response bias, and Social desirability bias. However, to minimize acquiescence
bias both negative and positive statement used for likert items used to measure perceived cost
and benefit for SHI. In addition, to minimize social desirability bias of the respondents the
anonymity was maintained.

30
7. CONCLUSION

The study shows there were low supports towards the proposed SHI among civil
servants working in Gulele sub-city.

Willingness to risk cross-subsidies, level of awareness towards SHI, preference of health

facility to utilize, perceived cost and benefit of the proposed SHI were influencing
factors for support towards the proposed SHI

The respondents do not appear to be well acquainted or generally supportive of the

notion of risk cross-subsidies and income cross-subsidies

31
8. RECOMMENDATION

Based on the finding the following recommendation has been forwarded

Ethiopian Health insurance Agency has to

Conduct more social dialogue, which includes negotiation and consultation with
different stakeholders on the proposed social health insurance before implementation of
the program to increase awareness and acceptance

Consider to involve more private health facilities in contracting with the agency as
health providers of members

Engage public around what SHI involves and about the rationale for fund pooling

Consider the cost to enroll in SHI as well as services to be included under the scheme.

Make more efforts to promote the scheme and educate the public through media,
campaigns and seminars

Incorporate public opinion in to design of SHI scheme

32
9. REFERENCES

1. J James CD, Hanson K, McPake B, Balabanova D, Gwatkin D, Hopwood I, et al. To retain or

remove user fees? Reflections on the current debate in low and middle-income countries. Appl
Health Econ Health Policy. 2006; 5:137–153.
2. Lagarde M, Palmer N. Evidence From Systematic Reviews to Inform Decision Making
Regarding Financing Mechanisms that Improve Access to Health Services for Poor People: A
Policy Brief Prepared for the International Dialogue on Evidence-Informed Action to Achieve
Health Goals in Developing Countries (IDEA Health).Geneva: World Health Organization
.2006.
3. Palmer N, Mueller DH, Gilson L, Mills A, Haines A. Health financing to promote access in low
income settings—how much do we know? Lancet.2004, 364:1365–1370.
4. Carrin G. Social health insurance in developing countries: A continuous challenge. International
Social Security Review. 2005. Vol.55( 2)
5. (Doetinchem O., Schramm, B., & Schmidt J. The Benefits and Challenges of Social Health
Insurance for Developing and Transitional Countries. Series International Public Health, 2006,
vol.18: 27-43. .

6. Acharaya A, Vellakkal S, Kalita S, Taylor F, Satija A, Burke M ,Ebrahim S. Do Social Health

Insurance Scheme in Developing Country Settings Improve Health Outcomes and Reduce the
Impoverishing effect of Healthcare payments for the poorest People. London School of Hygiene
& Tropical Medicine. London. UK: 2010.
7. World Health Organization & European Commission. Highlights on health in Germany.
Copenhagen: WHO Regional Office for Europe, 1999.
8. World Bank. Health care financing in low-income countries. In: Health Financing revisited.
Washington DC: 2006.
9. GulAbrejo F, Tasneem B. Social Health Insurance: can we ever make a case for Pakistan?
Karachi: Sheikh Department of Community Health Sciences, Aga Khan University, 2008,Vol.
58, ( 5)
10. William C. Hsiao R. Paul S. Social Health Insurance for Developing Nations. Washington, D C:
The International Bank for Reconstruction and Development / the World Bank, 2007.

33
11. Spaan E, Mathijssen J, Tromp N, Mc Bain, Florence. The impact of health insurance in Africa
and Asia: a systematic review.
12. Health care financing team, policy planning and finance general directorate federal ministry of
health .Ethiopian national health accounts 2007/[Link] Ababa: federal ministry of health,
2010.
13. Federal negarit gazeta of the federal democratic republic of Ethiopia. Addis Abeba .17thyear No
4 2nd December 2010.
14. Federal negarit gazeta of the federal democratic republic of Ethiopia. Addis Abeba 19thyear No 3
28th November 2012 (Regulation No.271/2005 ) page 6641 social health insurance scheme
council of ministers regulation to provide for social health insurance scheme.
15. Federal negarit gazeta of the federal democratic republic of Ethiopia.16th No 50 Addis Abeba 19
Augest 2010. prclamation no690/2010 social health insurance proclamation page 5494
16. Planning and programming department of federal ministry of health .health insurance strategy.
addis abeba: 2000.
17. Smith, M. J., Solanki, G. C., Lalloo, R., Myburgh, N. G., & Cornell, J. E. (2008). Support for
Social Health Insurance in South Africa. Journal of Health Management, 10, 1.)
18. Rothschild M, and Stiglitz J. E. Equilibrium in Competitive Insurance Markets: An Essay on the
Economics of Imperfect Information. Quarterly Journal of Economics. 1976,vol.90 (4):629–49
19. Gustafsson-Wright E, Asfaw A, & Van der Gaag, J. Willingness to pay for Health Insurance;
An Analysis of the Potential Market for new Low-cost Health Insurance Products in Namibia.
Social Science &Medicine. 2009, vol.69(9), 1351-1359
20. Ghosh S, Mondal S. Morbidity, Health Expenditure and Willingness to Pay For Health
Insurance Amongst the Urban Poor: A Case Study. Journal of Health Management, 2011,vol
.13:
21. Boateng D and Awunyor-Vitor [Link] insurance in Ghana: evaluation of policyholders’
perceptions and factors influencing Policy renewal in the Volta region). International Journal for
Equity in Health 2013, 12:50 .available at [Link]
22. Jehu-Appiah C, Aryeetey G, Agyepong I, Spaan E and Baltussen R. Household perceptions and
their implications for enrolment in the National Health Insurance Scheme in Ghana. Health
Policy and Planning 2011; 1–12
23. Arrow K. Uncertainty and the Welfare Economics of Medical Care. American Economic
Review.1963,vol .53 (5): 940–73
24. Gautam V and kumar M. A study on attitudes of Indian consumers towards insurance services.
Management research and practice. 2012;Vol 4 (1 ) :pp: 51-62

34
25. Ghosh, S., & Mondal, S. (2011). Morbidity, Health Expenditure and Willingness to Pay For
Health Insurance Amongst the Urban Poor: A Case Study. Journal of Health Management, 13,
26. Wang H, Switlick K, Ortiz C, Connor C, and Zurita [Link]. handbook how to make it
work. North Bethesda, Maryland: the United States Agency for International
[Link]
27. Doetinchem, Ole; Schramm, Bernd; Schmidt, Jean-Olivier: The Benefits and Challenges of
Social Health Insurance for Developing and Transitional Countries
28. McIntyre,D,Gooudge J, Harris B,Nxumalo N, Nkosi [Link] for National Health
insurance in South Africa:results of a national household survey. S Afr Med J2009;99:725-729
29. Sansui R.A. and Awe A.T. . Perception of National Health Insurance Scheme (NHIS) by Health
Care Consumers in Oyo State, Nigeria. Pakistan Journal of Social Sciences .2009, 6(1): 48-53
30. WHO. Thinking of introducing social health insurance? Ten [Link].2010
31. Evans M, Shisana O .Gender differences in public perceptions on National Health Insurance. S
Afr Med J 2012; 102(12):918-924. DOI:10.7196/SAMJ.639

32. Arris B , Nonhlanhla Nxumalo, John E Ataguba, Veloshnee Govender, Matthew Chersich and
Jane Goudge .Social solidarity and civil servants’ willingness for financial cross-subsidization in
South Africa: Implications for health financing reform. Journal of Public Health Policy. 2011;
32:162–183
33. Smith M. J. , Solanki G , Lalloo .R , Myburgh .N, Cornell .J. E. .Support for Social Health
Insurance in South [Link] of Health Management . 2008, 10(1): 1-8.

34. Mulupi .S, Kirigia D and Chuma .J. Community perceptions of health insurance and their
preferred design features: implications for the design of universal health coverage reforms in
Kenya. BMC Health Services Research. 2013,13:474

35. Reshmi B. Awareness, attitude and their correlates towards health insurance in an urban south
Indian .population management in health 2012, 16(1):32-35.

36. Nakyesa S. Attitudes of private not for profit health workers in jinja diocese. UMU Press
2009.7(1): 17-22.

35
37. Aloysious Byabashaija A. The knowledge and views of teachers in government educational
institutions: umu press 2009.7(1): 1-9.

38. Denis Alyela O. Knowledge, perceptions and attitudes of health [Link] press
2009.7(1):10-16

36
ANNEX I QUESTIONNIARE

PARTI ፡-socio-demographic and economic questions

Instruction:-for each of the following questions, please circle the number of the alternative
that fit for your response or fill the blank space

No Questions Possible choices/Answers skip

101 Sex 1. male
2. female
102 Age ___________in year
103 Religion 1. Muslim 3. orthodox
2. Protestant 4. catholic
[Link] specify_______
104 Marital status: 1. Single 4. Widowed
2. Divorced [Link]
3. married
105 House hold size ________________________
106 Education level 1. 4-6 thgrade
2. 7-8thgrade
3. 9-12th grade
4. 10+1-10+3 or certificate with technical and
vocational
5. diploma
6. digree
7. MA/Msc/Mph

107 occupation ________________________

(e.g. executive,secratory...)

108 Working organization/office ________________________

109 Work experience(total)
110 Income per month ________________________ETB
Spouse occupation 1. governmental employee
2. private organization employee
3. private worker
4. workless
111

PartII Questions to assess awareness level on the proposed SHI

37
In structure: For each of the following questions, please circle the number of the alternative that fit for your
response or fill the blank space or palce the mark of √ or ×

Questions skips
112 Have you ever heard 1. Yes
about the proposed 2. No
social health insurance
in Ethiopia?
From where you heard 1. Read on news paper
for the first time? 2. Television
3. Radio
113
4. Orientation from high administrative bodies
5. Other specify
What are the Yes No I don't know
contributors of social 1. Government employees............
health insurance 2. Private company employees.......
scheme? 3. Government and private company
114
Employees..................................
4. Pensioner.....................................

115 What percent of your gross

salary will be deducted for ________________________%
the contribution of social
health insurance scheme?
116 The frequency of 1. every month
contribution for the 2. every three month
proposed health insurance 3. every year
By members__________? 4. i don't know
117 What percent will be the 1. 3 % from gross salary
government or employer 2. 6 % from gross salary
contributes for social health 3. 10 % from gross salary
insurance? 4. I don't know
What are the beneficiaries Yes No I don't
of the proposed social 1. Natural children less than 18years old..........
health insurance schemes? 2. Step or adopted child.......................................
Fill in front of each boxes 3. Any children under guardian ship..................
with √ for your answer
4. Mentally and physically....................
118 5. impaired children who have
attained 18 years and can’t
sustain themselves..............................
6. Father and mother of member............
7. Spouse mother and father.............................

38
119 Which Health Yes No I don't
services are [Link] care
covered by social [Link] care
health insurance [Link] services
scheme? [Link] services
Yes No i don't
120 Which health
1. Any treatment outside Ethiopia...........
services are not
2. Treatment of injuries resulting from
covered by social
Natural diasasters,social unrest,
health insurance
Epidemic sand high risk sports............
scheme?
3. cosmetic surgeries ...............................
4. occupational injuries, traffic accidents
5. organ transplants ...............................
6. Dialysis except acute renal failure........
7. provision of eye glass and contact lenses
8. Dentures,crowns,bridges,implants and
root canal treatments..............................
9. provision of hearing aids.........................

121 Co-Payment for 1. 20%

outpatient services 2. 10%
from total cost of 3. 5%
the service.
4. I don't know
122 In which health 1. Government health intuition
facility the health 2. Private health institution
care will be given. 3. Both private and governmental health institution
4. I do not know.

39
PART III questions related to health conditions

Questions Skip

123 How do you rate the health 1. Very poor 4. good

status of your family? 2. Poor 5. Very good
3. Medium
Do you or other member 1. Yes
of the household have 2. No
124 chronic illness which
needs continuous follow
up?
Where do you and your 1. Private Heath Facility
family usually utilize 2. private hospital
during illness.
3. Public health center
125 4. Public hospital
5. Traditional healer
6. Other (specify)
Why did you go there? 1. The HF was physically accessible
2. The HF was not expensive
3. The health facility not too crowded
126
4. The health service was courteous
5. The health service was efficacious/ effective
6. Other (specify)
Does there anybody who 1. Yes
127 covers your health care 2. no
free?
128 If there, Who covers?
[Link]
[Link]
[Link]
[Link]/specify
129 How did you see finding
money to pay for the health 1. Difficult
care? 2. Not difficult

40
 PART IV willingness to cross-subsidize

Choose one correct answer from lists of choices for each question in the right of the table

Willingness to risk cross subsidies skip

130 I would be willing to pay the same amount of money for each 1. I am volunteer
month as everyone else, even though others who are more sick 2. I am not volunteer
than I am will use the services more
Willingness to income cross subsidies
131 Do you support that payment for health care should be 1. I support
increased based on wealth? 2. I don't support

A pictorial option included in the survey to elaborate question No.133

Poor or those
with low Medium
income economic level

or those with
medium
income

Rich or those
with high
income

PART V Questions, which assess perception on SHI, related to benefit and cost

41
 For each statement in the left question box, place the mark of √ or × at space on the right
box to indicate your level of your agreement for the statements.

Statements to assess civil servants' Very disagree neutral agree Very

perception on SHI regarding it's disagree agree
benefit.
132 The proposed Social health insurance will
save money from paying for medical bills.
133 Will not need to borrow money for
treatment because of the proposed social
health insurance
134 The proposed Social health insurance
prevents from unexpected health
expenditure for health care.
135 The proposed social health insurance will
increase access for health care
136 The proposed Social health insurance will
improve equity of health service.
137 The proposed Social health insurance will
increase utilization of health service.
138 The proposed Social health insurance will
create solidarity between members
139 Social Health insurance will improve the
quality of health care services.
140 The proposed Social Health insurance will
limit patient’s freedom to choose health
care provider.
141 The proposed Social health insurance will
not benefit me since government will
manage it.
142 The proposed social health doesn't not
cover essential health care services for
members
143 The proposed Social health insurance does
not enable most of the family members
to be beneficiary
144 Joining social health insurance will not
benefit me
Part VI: - Questions to assess civil servants perception related to cost

42
For each statement in the left question box, place the mark of √ or × at space on the right box to
indicate your level of your agreement for the statements

Statements to assess civil servants' Very disagree neutral agree Very

perception on social health insurance disagree agree
regarding its cost
145 Premium is low in related to benefit
package

146 The Co-payment fee for service is

low
147 The contribution for the scheme is
High in related to salary
148 Government contribution for social
Health insurance scheme is low
149 We should not pay for the scheme

PART VII:-Questions to assess civil servants support for proposed SHI

Strongly oppose neutral support Strongly

oppose support
150 Do you support the start of
The proposed social health
insurance

ANNEX II AMHARIC VERSION QUESTIONNIARE

ክፍል አንድ፡-ማህበራዊና እና ኢኮኖሚያዊ ጥያቄዎች

43
 መመሪያ ፡-በጥያቂዉ ሳጥን ዉስጥ በግራ በኩል ላሉ ጥያቄዎች በቀኝ በኩል ከተዘረዘሩት የመልስ ምርጫ
ዎች የመረጡትን ያክብቡ ወይንም ባለዉ ክፍት ቦታዎች መልሱን ያስፍሩ፡

No ጥያቂዎች ምርጫ እና መልሶቻቸዉ ይዝለሉ

101 ፆታ 1. ወንድ
2. ሴት
102 እድሜዎ ስንት ነዉ ____________ አመት
103 ሀይማኖት 1. ሙስሊም 4. ካቶሊክ
2. ፐሮቴስታንት 5. ሌላ ከሆነ ይገለፅ____________
3. ኦርቶዶክስ

104 የጋብቻ ሁኔታ 1. ያላገባ 4.ባለቤቱ የሞተበት/የሞተባት

2. የተፋታ 5.የተለያዩ
3. ያገባ
105 በአንድ ቤት ዉስጥ ____________
የሚኖሩ የቤተሰብ ብዛት
106 የትምህርት ደረጃ 1. 4-6 ኛ ክፍል
2. 7-8 ኛ ክፍል
3. 9-12ኛ ክፍል
4. 10+1 - 10+3 ወይም በቴክኒክና ሞያ ሰርተፍኬት
5. ዲፕሎማ
6. የመጀመሪያ ዲግሪ
7. ሁለተኛ ዲግሪ
107 የስራዎ አይነት ________________________
(ምሳሌ፡-ሀላፊ፤ፀሀፊ፤
108 የሚሰሩበት መስሪያ ቤት ________________________
109 የአገልግሎት ዘመን ____________________
(አጠቃላይ) ወር/ዓመት
110 ወርሀዊ የወር ገቢ __________________ብር
111 የባለቤትዎ የስራ ሁኔታ 1. የመንግስት መስራያ ቤት ሰራተኛ
(ያላገቡ ከሆነ ወደ 2. የግል መስሪያ ቤት ሠራተኛ
ሚቀጥለዉ ጥያቄ ይሂዱ) 3. የግል ሠራተኛ
4. ስራ የሌለዉ 112

ክፍል ሁለት፡- ሰለ ማህበራዊ ጤና መድህን ያለንን ግንዛቤ የሚዳስሱ ጥያቂዎች

መመሪያ፡- በጥያቂ ሳጥን ዉስጥ በግራ በኩል ላሉ ጥያቄዎች በቀኝ በኩልትይዩ ከተዘረዘሩት የመልስ ምርጫዎች የመረጡትን
ያክብቡ ወይንም በተዘረዘሩት የመልስምርጫዎች ፊት ለፊት በተቀመጡት ክፍት ሳጥኖች ዉስጥ የመረጡትን √ ምልክት በማስፈር
ይመለሱ ፤በተጨማሪም ምርጫ ለሌላቸዉ ጥያቄዎች በቀኝ በኩል በተቀመጡት ክፍት መስመርላይ መልሶን ያስቀምጡ ፡፡

ጥያቄዎች ይዝለል

44
112 በኢትዮጲያ ዉስጥ ስለሚጀመረዉ 1. አዎ
የማህበራዊ ጤና መድህን ሰምተህ 2. የለም ሰምቼ አላዉቅም
ታዉቃለህ?
113 መረጃዉን ለመጀመሪያ ግዚ ከየት 1. ከ ጋዜጣ አንብቤ 4.ከባልስጣን አካላት
አገኘህ ? 2. በቴሌቭዠን 5.ሌላ ካለ ይገለፅ
3. በ ሬድዮን
4. ከስራ ባልደረባ

114 ለማህበራዊ ጤና መድህን ስራዐት አዎ የለም አላዉቅም

አባል ሆነዉ መዋጮ የሚያዋጡት
እነማን ናቸዉ? 1. የመንግስት ቤት ሰራተኞች
(የመረጡትን በ እያንዳንዱ ምርጫ 2. የግልመስሪያ ቤት ሰራተኞች
አጠገብ ባለዉ ሳጥን ዉስጥ የ √ 3. ጡረተኞች
ምልክት ያኑሩ) 4. በግል የሚሰሩ

115 ለ ጤና መድህን ስርአቱ ከ ጠቅላላ 1. %

ደሞዝ ለመዋጮ ከ አባላት
የሚቆረጠዉ 2.አላዉቅም

116 አባላት ለ ጤና መድህኑ ክፍያ 1. በየወሩ 3.በአመት አንድ ግዜ

የሚፈፅሙት በየስንትግዜ ነዉ? 2. በየሶስት ወሩ 4.አላዉቅም
117 መንግስት ወይንም ቀጣሪ መስራያ 1. ከጠቅላላ የወር ደሞዝ 3 %
ቤት ለጤና መድህን ስራዐቱ አባል 2. ከጠቅላላ የወር ደሞዝ 6 %
ምን ያህል ያዋጣል? 3. ከጠቅላላ የወር ደሞዝ 10 %
4. አላዉቅም
118 በማህበራዊ ጤናመድህኑ አማካኝነት አዎ የለም አላዉቅም
የህክምና 1.ዕድሜው ከ18 ዓመት በታች የሆነ
አገልግሎትየማግኘትመብት ያለዉ የአባል የስጋ ልጅ………………
የአባል ቤተሰብ 2.የእንጀራ ወይም የጉዲፈቻ ልጅ………..
________________ 3.አባሉ በህግ መሠረት የአሳዳጊነት ኃላፊነት
(የመረጡትን በ እያንዳንዱ ምርጫ የተጣለበትን ልጅ................................
አጠገብ ሳጥን የ √ ምልክት ያኑሩ) 4.ዕድሜያቸው ከ18 ዓመትያላነሰ ..........
ራሳቸውንለማስተዳደር የማይችሉ .........
5.የአእምሮ በሽተኛ እናአካል ጉዳተኛ ልጆች….
6.የአባል እናት ወይም አባት ………….
7.የትዳር አጋር እናት ወይም አባት …….

45
119 የማህበራዊ የጤና መድህን አዎ የለም አላዉቅም
ስርዐት ተጠቃሚዎች ምን 1. የተመላላሽ ህክምና ………..
አይነት የጤና አገልግሎቶችን 2. የተኝቶ ህክምና……………….
ከኤጀንሲዉ ጋር ዉል ከገቡ 3. የወሊድ አገልግሎት……….
የጤና ጠቋማት የማግኘት መብት 4. የቀዶ ህክምና……..……….
ይኖራቸዋል?

120 የጤና መድህኑ የማይሸፍናቸዉ አዎ የለም አላዉቅም

አገልግሎቶች 1. ከኢትዮጲያ ዉጪ የሚደረግ ህክምና …………….
2. በተፈጥሮ አዳጋ፣በማህበራዊ ብጥብጥ
በወረርሽኝእናበስፖርታዊ ዉድድሮች
ለሚደርሱ ጉዳቶች የሚደረግ ህክምና…………
3. የዉበት ቀዶ ጥገና ………………………………
4. የስራላይ ጉዳቶች እናየትራፊክ
አደጋዎች……………………………………………
5. የአካል ማዘዋወር……………………………………
6. ለረጅም ግዜ የሚደረግ የኩላሊት
ዲያሊሲስ ህክምና…………………………………
7. የአይን መነፅርና ኮንታክትሌንስ
አቅርቦት………………………………………………
8. ሰዉ ሰራሽ ጥርስ ማስተካከልና ጥር
ማስተካከል………………………………………………
9. የመስማት ሀይልን የሚያግዙ መሳሪያዎች……………….

121 ለተጠቃሚዎች የጤና መድህኑ 1. 20%

ከሚሸፍነዉ የህክምና ወጪ ሌላ 2. 10%
ተጠቃሚዎች ተመላላሽ ህክምና 3. 5%
በሚያገኙበት ወቅት ከጠቅላላዉ 4. አላዉቀዉም
የህክምና ወጪዉ ላይ ተሰልቶ
በቀጥታ በጥሬ ገንዘብ
የሚከፈለዉ ክፍያ ከጠቅላላዉ
የህክምና ወጪ ምን ያህል
ፐርስንቱን ነዉ?
122 የትኞቹ የጤና ተቋማት ናቸዉ ከ 1. መንግስታዊ የጤና ተቋማት(ጤና ጣቢያዎች ወይም ሆስፒታሎች)
ማህበራዊ ጤና መድህኑ ጋር 2. የግል የጤና ተቋማት(የግል ሆስፒታሎችወይምክልኒኮች)
ዉል ፈጽመዉ ለ ተጠቃሚዎች
3. የመንግስታዊ እና የግል ጤና ተቋማት
የጤና አገልግሎት መስጠት
የሚችሉት? 4. አላዉቅም

46
 ክፍል ሦስት፡- ጤና እና ከጤና ጋር የተያያዙ ጉዳዮች

በጥያቂዉ ሳጥን ዉስጥ በግራ በኩል ላሉ ጥያቄዎች በቀኝ በኩል ከተዘረዘሩት የመልስ ምርጫዎች

ዉስጥ አንዱን የመረጡትን ያክብቡ ወይንም የተለየ መልስ ካሎዎት ባለዉ ክፍት መስመር ላይ

መልሱን ያስፍሩ፡፡

ጥያቄዎች ይዘለል
123 የቤተሰብህን የጤንነት ሁኔታ እንዴት 1. በጣም ደካማ ነዉ 4 . ጥሩ ነዉ
ትለከዋለህ? 2. ደካማ ነዉ 5. በጣም ጥሩ
3. መ ካ ከ ለ ኛ ነዉ
124 በቤታችሁ ዉስጥ የማያቋርጥ የህክምና
ክትትል የሚያስፈልገዉ አባል አለ? 1. አዎን
2. የ ለ ም
125 በቤተሠብህ አባል ላይ ህመም ቢከሰት 1. በግል ክልኒክ
በአብዛኛዉ ህክምና የምትከታተሉት የት ነዉ? 2. በግል ሆስፒታል
3. ከግል መድሃኒት ቤት
4. የመንግስት ጤናጣቢያ
5. የመንግስት ሆስፒታል
6. ባህላዊ ሀኪም ቤት
7. ሌላ ካለ ይገለፅ
126 ለምንድን በእንደዚህ ሁኔታ ለመከታተል 1. የጤና ተቃሙ በቅርብ ስለሚገኝ
መረጣችሁ? 2. የጤና ተቃሙ የአገልገልት ክፍያ ዉድ
ስላለሆነ
3. የጤና ተቃሙ በ ተገልጋይ የተጨናነቀ
ስላለሆነ
4. የጤና አገልግሎቱ በትህትና ስለሚሰጥ
5. ዉጤታማ የህክምና አገልገሎት ስለሚሰጥ
6. ሌላ ካለ ይገለፅ
127 የቤተሰብህን የህክምና ወጨ በነፃ የሚሸፍን 1. አዎ አለ
አለ? 2. የለም

128 የሚሸፈን ካለ የሚሸፍነዉ ማነዉ? 1. መ ስ ሪ ያ ቤ ት

2. በመንግስት/በነፃ
3. ከህብረተሠቡ
4. ሌላካለ ይገለፅ
129 ለህክምና አገልግሎት የሚሆን ገንዘብ ማግኝት 1. ከባድ
እንዴት ታያዋለህ? 2. ከባድ አይደለም

47
 ክፍል አራት፡-የመደጋገፍ ፍቃደኝነት

በጥያቂ ሳጥን ዉስጥ በግራ በኩል ላሉ ጥያቄዎች በቀኝ በኩልትይዩ ከተዘረዘሩት የመልስ
ምርጫዎች የመረጡትን ያክብቡ፡፡

የሌሎችን የበሽታ ተጋላጭነትን የመጋራት ፍቃደኝነት ይዘለል

130 ምንም እንኳን የህክምና አገልግሎቱን ከእርሶ በበለጠ በህመም 3. አዎ ፍቃደኛ ነኝ
ምክንያት ሊጠቀሙ የሚችሉ ሰዎች ሊኖሩ ቢችሉም ሁሉም 4. የለምፍቃደኛ
እንደሚያዋጣዉ እኩል የገንዘብ መጠን በየወሩ ማወጣት ፈቃደኛ አይደለሁም
ኖት ወይ ?

የሌሎችን የህክምናን ወጪ ለ መደገፍ ፍቃደኝነት

131 ለህክምና አገልገሎት የሚሆን የገንዘብ ክፍያ እንደገቢ መጠን ቢከፈል 1. አዎ እደግፋለሁ
ማለተም ከፈተኛ ገቢ ያላቸዉ ሰዎች ዝቅተኛ ገቢ ካላቸዉ ሰዎች 2. የለም አልደግፍም
የበለጠ እነደገቢያቸዉ መጠን የሚጨምር የህክምና አገልገሎት ክፍያ
መክፈላቸዉን ትደግፋለህ

ድሀ
ወይንም
መካከለኛ
ዝቅተኛ
ገቢ ገቢ ያላቸዉ
ያላቸዉ
ያyያላቸዉ

ለህከምናየሚከፍል

ሀብታም
ወይንም
ከፍተኛ ገቢ
ያላቸዉ

48
 ክፍል አምስት፡-ማህበራዊ ጤና መድህን ስለሚሰጠዉ አጠቃላይ ጥቅም ያለዉን እይታ
የሚዳስሱ ጥያቂዎች፡፡

በጥያቄዉ ሳጥን ዉስጥ በግራ በኩል ለተጠቀመጡት ከ ማህበራዊ ጤና መድህን ጥቅም ጋር ለተያያዙ
አረፍተ ነገሮች የመስማማቶን ወይንም ያለመስማማቶን ደረጃ በቀኝ በኩል ትይዩ ባሉት ክፍት ቦታዎች
ላይ የ √ ወይንም × ምልክት ያኑሩ

የመንግስት ሰራተኞች ማህበራዊ ጤና መድህን በጣም አልስማም መስማማትም እስማማለ በጣም

ስለሚሰጠዉ አጠቃላይ ጥቅም ያላቸዉን እይታ የሚዳስሱ አልስ አለመስማትም ሁ እስማማ
አረፍተ ነገሮች፡፡ ማም አልችልም ለሁ
132 የማህበራዊ ጤና መድህኑ ለህክምና ተብሎ ከሚከፍል
የገንዘብ ወጪ ያድነናል፡፡
133 በ ማህበራዊ ጤና መድህኑ ምክንያት ለህክምና ሲባል
ገንዘብ መበደር አያስፈልገንም፡፡
134 የማህበራዊ ጤና መድህኑ ድንገተኛ የሆነ እናያልታሰበ
ከፍተኛ የኪስ ወጪን ለህክምና ከማዉጣት ይከላከላል፡፡

135 የማህበራዊ ጤና መድህኑ ስርዐት መሰረታዊ የጤና

አገልግሎት ለአባላት ተደራሽ እነዲሆን ያስችላል፡፡
136 የማህበራዊ ጤና መድህኑ ስርዐት ሁሉም ሠዉ
እንዳቅሙ እንዲከፍል እና በጤና መድህኑ የሚሰጠዉን
አገልግሎት እኩል ተጠቃሚ እንዲሆን ያደርጋል፡፡
137 የማህበራዊ ጤና መድህኑ የህክምና ወጪን በመፍራት
የጤና አገልገሎትን አለመጠቀምን በመቀነስየጤና
አገልግሎት ተጠቃሚነትን ያሻሽላል፡፡
138 የማህበራዊ ጤና መድህኑ ገንዘብ ያለው የሌለውን እና
ጤነኛው ህመምተኛውን የሚደግፍበትን ሁኔታ
ይፈጥራል፡፡
139 የማህበራዊ ጤና መድህኑ ስርዐት የጤና አገልግሎት
ጥራትን ያሻሽላል፡፡
140 የማህበራዊ ጤና መድህኑ የህክምና አገልግሎት ሰጪ
ተቋማትን የመምረጥ ነፃነት ያሳጣል
141 የማህበራዊ ጤና መድህኑ በመንግስት መስሪያ ቤት
ስለሚስተዳደር አባላት እና ቤተሠቦቻቸዉ በጤና
መድህኑ ተጠቃሚዎች አይሆኑም፡፡
142 የማህበራዊ ጤና መድህን መሰረታዊ የጤና አገልግሎትን
ባለመሸፈኑ አባላትንና ቢተሰቦቻቸዉን ተጠቃሚ
አያደርግም ፡፡
143 የማኅበራዊ ጤና መድህንሥርዓት የአባላትን አብዛኛዉን
የቤተሰብ አባል በጤና መድህኑ በሚሸፈነዉ የጤና
አገልግሎት ተጠቃሚዎች አያደርግም፡፡

144 የጤና መድህኑን ብቀላቀል አይጠቅመኝም

፡፡

49
 ክፍል አምስት፡-ማህበራዊ ጤና መድህን ስለሚያስወጣዉ አጠቃላይ መዋጮ ያለዉን እይታ
የሚዳስሱ ጥያቂዎች፡፡

በጥያቄዉ ሳጥን ዉስጥ በግራ በኩል ለተጠቀመጡት ማህበራዊ ጤና መድህን ከሚያስወጣዉ ወጪ

ጋር ለተያያዙ አረፍተ ነገሮች የመስማማቶን ወይንም ያለመስማማቶን ደረጃ በቀኝ በኩል ትይዩ
ባሉት ክፍት ቦታዎች ላይ የ √ ወይንም × ምልክት ያኑሩ፡፡

የመንግስት ሰራተኞች የማህበራዊ ጤና መድህን በጣም አልስማም መስማማትም እስማማለሁ በጣም

አባላትን ስለ ሚያስወጣዉ ክፍያ ያላቸዉን አልስማም አለመስማትም እስማማ
አጠቃላይ እይታ የሚዳስሱ አረፍተ ነገሮች አልችልም ለሁ

145 የሚከፈለዉ መዋጮ ከሚሸፈነዉ የጤና

አገልግሎት አንፃር ዝቅተኛ ነዉ

146 ተመላላሽ ህክምና በሚያገኙበት ወቅት

ከጠቅላላዉ የህክምና ወጪዉ ላይ ተሰልቶ
በቀጥታ በጥሬ ገንዘብ የሚከፈለዉ ክፍያ
አንስተኛ ነዉ፡፡

147 የሚከፈለዉ መዋጮ ከሚከፈለን ደሞዝ አንጻር

በጣም ከፍተኛ ነዉ፡፡

148 መንግስት ለማህበራዊ ጤና መድህኑ ለሰራተኛ

የሚያዋጣዉ መዋጮ አነስተኛ ነዉ ፡፡
149 ለማህበራዊ ጤና መድህኑ ሰራተኛዉ ከደሞዙ
መክፈል የለበትም፡፡

ክፍል ሰባት-በቅርቡ ተግባራዊ ሊደረግ የታሰበዉን የማህበራዊ ጤና መድህን መጀመር ያሎትን ድጋፍ
የሚዳስስ ጥያቂ
በጣም አልደግፍ መደገፍም እደግፋለሁ በጣም
አልደግፍም ም አለመደገፍም አልደግ
አልችልም ፍመ

150 በቅርቡ ተግባራዊ ሊደረግ የታሰበዉን

የማህበራዊ ጤና መድህን መጀመር ትደግፋለህ

ስለ ትብብሮ አመሰግናልሁ!!!!

50