Pub Date : 2023-12-17DOI: 10.1101/2023.12.15.23300030
Anandita Pattnaik
Background The World Health Organisation has declared climate change the biggest menace to global health in the 21st century. The health consequences of climate change are well documented. It is also established that vulnerable groups disproportionately bear the effects of climate change. Climate inaction or inequitable climate action can worsen the prevailing health inequalities. Thus, there is an urgent need to implement effective and equitable strategies to minimise the adverse effects and maximise the co-benefits of climate action. The United Kingdom envisions becoming a net-zero carbon country by 2050. The Mayor of London declared a climate emergency in 2018 and aims to make London a carbon-neutral city by 2030. As a result, the London boroughs have published their climate action plans (CAPs) outlining their adaptation and mitigation strategies. But due to a lack of proper guidelines and framework, the plans vary considerably and how health equity is embedded into these documents is currently unknown. This project aims to explore the extent to which health issues are addressed through the CAPs of the London boroughs and if health inequities would be reduced through the greenhouse gas mitigation strategies in the transport sector.
{"title":"Role of Health Equity in the Climate Action Plans of London Boroughs: A Health Policy Report","authors":"Anandita Pattnaik","doi":"10.1101/2023.12.15.23300030","DOIUrl":"https://doi.org/10.1101/2023.12.15.23300030","url":null,"abstract":"<strong>Background</strong> The World Health Organisation has declared climate change the biggest menace to global health in the 21<sup>st</sup> century. The health consequences of climate change are well documented. It is also established that vulnerable groups disproportionately bear the effects of climate change. Climate inaction or inequitable climate action can worsen the prevailing health inequalities. Thus, there is an urgent need to implement effective and equitable strategies to minimise the adverse effects and maximise the co-benefits of climate action. The United Kingdom envisions becoming a net-zero carbon country by 2050. The Mayor of London declared a climate emergency in 2018 and aims to make London a carbon-neutral city by 2030. As a result, the London boroughs have published their climate action plans (CAPs) outlining their adaptation and mitigation strategies. But due to a lack of proper guidelines and framework, the plans vary considerably and how health equity is embedded into these documents is currently unknown. This project aims to explore the extent to which health issues are addressed through the CAPs of the London boroughs and if health inequities would be reduced through the greenhouse gas mitigation strategies in the transport sector.","PeriodicalId":501386,"journal":{"name":"medRxiv - Health Policy","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-12-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138818484","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-12-05DOI: 10.1101/2023.12.05.23299446
Akram Mahani, Joonsoo Sean Lyeo, Agnes Fung, Kelly Husack, Nazeem Muhajarine, Tania Diener, Chelsea Brown
While there is a wealth of literature on the impact of urban design on health, our understanding of the factors that influence integration of health into urban design is limited. With the growing recognition of cities playing a leading role in enhancing health equity and population health outcomes, it becomes crucial to examine the perspectives and experiences of municipal actors concerning health and equity. To address this gap, we interviewed 30 stakeholders engaged with urban design policy- and decision-making at the City of Regina in Saskatchewan, Canada. Our research uncovered a lack of shared understanding of health among municipal actors. From our findings, we identified several factors that serve as either facilitators or barriers to integrating health and equity in urban design policies. This case study enhances our understanding of these factors and provide recommendations for developing healthy urban design policies. Our findings underscore the importance of adopting an integrated and holistic approach for healthy and equitable urban design. As urbanisation continues to bring a greater share of the world population into urban areas, it becomes imperative to deepen our understanding of how municipal governance can be leveraged to create environments conducive to the well-being of their residents.
{"title":"At the end of the day, it is Council's decision: Integration of health and equity into urban design and urban planning decisions and policies in Regina Saskatchewan","authors":"Akram Mahani, Joonsoo Sean Lyeo, Agnes Fung, Kelly Husack, Nazeem Muhajarine, Tania Diener, Chelsea Brown","doi":"10.1101/2023.12.05.23299446","DOIUrl":"https://doi.org/10.1101/2023.12.05.23299446","url":null,"abstract":"While there is a wealth of literature on the impact of urban design on health, our understanding of\u0000the factors that influence integration of health into urban design is limited. With the growing\u0000recognition of cities playing a leading role in enhancing health equity and population health\u0000outcomes, it becomes crucial to examine the perspectives and experiences of municipal actors\u0000concerning health and equity. To address this gap, we interviewed 30 stakeholders engaged with\u0000urban design policy- and decision-making at the City of Regina in Saskatchewan, Canada. Our\u0000research uncovered a lack of shared understanding of health among municipal actors. From our\u0000findings, we identified several factors that serve as either facilitators or barriers to integrating\u0000health and equity in urban design policies. This case study enhances our understanding of these\u0000factors and provide recommendations for developing healthy urban design policies. Our findings\u0000underscore the importance of adopting an integrated and holistic approach for healthy and\u0000equitable urban design. As urbanisation continues to bring a greater share of the world population\u0000into urban areas, it becomes imperative to deepen our understanding of how municipal governance\u0000can be leveraged to create environments conducive to the well-being of their residents.","PeriodicalId":501386,"journal":{"name":"medRxiv - Health Policy","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-12-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138520972","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-12-01DOI: 10.1101/2023.11.30.23299238
Micaela Gal, Alison Cooper, Natalie Joseph-Williams, Elizabeth Doe, Ruth Lewis, Rebecca Jane Law, Sally Anstey, Nathan Davies, Amy Walters, Robert Orford, Brendan Collins, Lisa Trigg, Chris Roberts, Sarah Meredith, Steven Macey, Andrew Carson-Stevens, Jane Greenwell, Ffion Coomber, Adrian Edwards
The Wales COVID-19 Evidence Centre (WCEC) was established from 2021-23 to ensure that the latest coronavirus (COVID-19) relevant research evidence was readily available to inform health and social care policy and practice decision-makers. Although decisions need to be evidence-based, ensuring that accessible and relevant research evidence is available to decision-makers is challenging, especially in a rapidly evolving pandemic environment when timeframes for decision-making are days or weeks rather than months or years. We set up knowledge mobilisation processes to bridge the gap between evidence review and informing decisions, making sure that the right information reaches the right people at the right time.
{"title":"Knowledge mobilisation of rapid evidence reviews to inform health and social care policy and practice in a public health emergency: appraisal of the Wales COVID-19 Evidence Centre processes and impact, 2021-23","authors":"Micaela Gal, Alison Cooper, Natalie Joseph-Williams, Elizabeth Doe, Ruth Lewis, Rebecca Jane Law, Sally Anstey, Nathan Davies, Amy Walters, Robert Orford, Brendan Collins, Lisa Trigg, Chris Roberts, Sarah Meredith, Steven Macey, Andrew Carson-Stevens, Jane Greenwell, Ffion Coomber, Adrian Edwards","doi":"10.1101/2023.11.30.23299238","DOIUrl":"https://doi.org/10.1101/2023.11.30.23299238","url":null,"abstract":"The Wales COVID-19 Evidence Centre (WCEC) was established from 2021-23 to ensure that the latest coronavirus (COVID-19) relevant research evidence was readily available to inform health and social care policy and practice decision-makers. Although decisions need to be evidence-based, ensuring that accessible and relevant research evidence is available to decision-makers is challenging, especially in a rapidly evolving pandemic environment when timeframes for decision-making are days or weeks rather than months or years. We set up knowledge mobilisation processes to bridge the gap between evidence review and informing decisions, making sure that the right information reaches the right people at the right time.","PeriodicalId":501386,"journal":{"name":"medRxiv - Health Policy","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138542974","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-29DOI: 10.1101/2023.11.28.23299146
Jinyi Zhu, Janice Jhang, Hanxuan Yu, Alvin I Mushlin, Hooman Kamel, Nathaniel Alemayehu, John Giardina, Ajay Gupta, Ankur Pandya
Background Carotid artery stenosis (50-99% extracranial internal carotid artery narrowing) is a risk factor for ischemic stroke. However, no population-based studies have directly assessed the benefits and harms of screening for asymptomatic carotid artery stenosis (ACAS), and the CREST-2 trial is currently evaluating the efficacy of revascularization vs. intensive medical management for ACAS patients. Given this gap, the United States Preventive Services Task Force (USPSTF) currently recommends against screening for ACAS in the general population. Because ACAS prevalence and ischemic stroke risk vary by clinical risk factors, we sought to quantify the cost-effectiveness of screening for ACAS by cardiovascular disease risk-based sub-groups.
{"title":"Cost-Effectiveness of Screening for Asymptomatic Carotid Artery Stenosis Based on Atherosclerotic Cardiovascular Disease Risk Thresholds","authors":"Jinyi Zhu, Janice Jhang, Hanxuan Yu, Alvin I Mushlin, Hooman Kamel, Nathaniel Alemayehu, John Giardina, Ajay Gupta, Ankur Pandya","doi":"10.1101/2023.11.28.23299146","DOIUrl":"https://doi.org/10.1101/2023.11.28.23299146","url":null,"abstract":"<strong>Background</strong> Carotid artery stenosis (50-99% extracranial internal carotid artery narrowing) is a risk factor for ischemic stroke. However, no population-based studies have directly assessed the benefits and harms of screening for asymptomatic carotid artery stenosis (ACAS), and the CREST-2 trial is currently evaluating the efficacy of revascularization vs. intensive medical management for ACAS patients. Given this gap, the United States Preventive Services Task Force (USPSTF) currently recommends against screening for ACAS in the general population. Because ACAS prevalence and ischemic stroke risk vary by clinical risk factors, we sought to quantify the cost-effectiveness of screening for ACAS by cardiovascular disease risk-based sub-groups.","PeriodicalId":501386,"journal":{"name":"medRxiv - Health Policy","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138520969","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-28DOI: 10.1101/2023.11.26.23299018
Sara Rotenberg, Sara Ryan, Sue Ziebland, John Ganle
Introduction Disabled people often report poor treatment by health workers, and health workers often report wanting more training about how to care for disabled people. However, existing disability training for health workers is usually delivered in one-off interventions, with little follow-up, evaluation, and focus on long-term learning. This insufficiency makes it important to understand how disability training for health workers can be more effective. Therefore, we interviewed stakeholders involved in an existing disability training intervention in Ghana to understand how disability training for health workers could be improved.
{"title":"Participant perceptions of disability training for health workers: a qualitative study in Ghana","authors":"Sara Rotenberg, Sara Ryan, Sue Ziebland, John Ganle","doi":"10.1101/2023.11.26.23299018","DOIUrl":"https://doi.org/10.1101/2023.11.26.23299018","url":null,"abstract":"<strong>Introduction</strong> Disabled people often report poor treatment by health workers, and health workers often report wanting more training about how to care for disabled people. However, existing disability training for health workers is usually delivered in one-off interventions, with little follow-up, evaluation, and focus on long-term learning. This insufficiency makes it important to understand how disability training for health workers can be more effective. Therefore, we interviewed stakeholders involved in an existing disability training intervention in Ghana to understand how disability training for health workers could be improved.","PeriodicalId":501386,"journal":{"name":"medRxiv - Health Policy","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138520971","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-20DOI: 10.1101/2023.11.20.23298759
Elizabeth Goult, Laura Andrea Barrero Guevara, Michael Briga, Matthieu Domenech de Cellès
The persistence of measles in many regions demonstrates large immunity gaps, resulting from incomplete or ineffective immunization with measles-containing vaccines (MCVs). A key factor affecting MCV impact is age, with infants receiving dose 1 (MCV1) at older ages having a reduced risk of vaccine failure, but also an increased risk of contracting infection before vaccination. Here, we designed a new method—based on a transmission model incorporating realistic vaccination delays and age variations in MCV1 effectiveness—to capture this risk trade-off and estimate the optimal age for recommending MCV1. We predict a large heterogeneity in the optimal ages (range: 6–20 months), contrasting the homogeneity of observed recommendations worldwide. Furthermore, we show that the optimal age depends on the local epidemiology of measles, with a lower optimal age predicted in populations suffering higher transmission. Overall, our results suggest the scope for public health authorities to tailor the recommended schedule for better measles control.
{"title":"Estimating the optimal age for infant measles vaccination","authors":"Elizabeth Goult, Laura Andrea Barrero Guevara, Michael Briga, Matthieu Domenech de Cellès","doi":"10.1101/2023.11.20.23298759","DOIUrl":"https://doi.org/10.1101/2023.11.20.23298759","url":null,"abstract":"The persistence of measles in many regions demonstrates large immunity gaps, resulting from incomplete or ineffective immunization with measles-containing vaccines (MCVs). A key factor affecting MCV impact is age, with infants receiving dose 1 (MCV1) at older ages having a reduced risk of vaccine failure, but also an increased risk of contracting infection before vaccination. Here, we designed a new method—based on a transmission model incorporating realistic vaccination delays and age variations in MCV1 effectiveness—to capture this risk trade-off and estimate the optimal age for recommending MCV1. We predict a large heterogeneity in the optimal ages (range: 6–20 months), contrasting the homogeneity of observed recommendations worldwide. Furthermore, we show that the optimal age depends on the local epidemiology of measles, with a lower optimal age predicted in populations suffering higher transmission. Overall, our results suggest the scope for public health authorities to tailor the recommended schedule for better measles control.","PeriodicalId":501386,"journal":{"name":"medRxiv - Health Policy","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138520970","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-07-14DOI: 10.1101/2023.07.11.23292526
Hlologelo Malatji, Frances Griffiths, Jane Goudge
In low and middle-income countries (LMICs), community health workers (CHWs) play a critical role in delivering primary health care (PHC) services to vulnerable populations. In these settings, they often receive low stipends, function with a lack of basic resources and have little bargaining power with which to demand better working conditions. In this article, we examine CHWs’ employment status, their struggle for recognition as health workers, and their activities to establish labour representation in South Africa. Using a case study approach, we studied seven CHW teams located in semi-urban and rural areas of Gauteng and Mpumalanga Provinces, South Africa. We used in-depth interviews, focus group discussions and observations to gather data from CHWs and their representatives, supervisors and PHC facility staff members. The rural and semi-urban sites CHWs were poorly supervised, resourced and received meagre remuneration, their employment outsourced, without employment benefits and protection. The lack of career progression opportunities demotivated the CHWs, particularly those keen to establish a career in health. In the semi-urban sites, CHWs established a task team to represent them that held regular meetings and often used violent and disruptive strategies against clinic, district and provincial management, which often led to tensions and conflicts with facility staff and programme coordinators. After a meeting with the local provincial legislature, the task team joined a labour union (NEHAWU) in order to be able to participate in the local Bargaining Council. Though they were not successful in getting the government to provide permanent employment, the union negotiated an increase in stipend from R2 500 (136 USD) to R3 500 (192 USD). In contrast, in the rural sites, the CHWs were not actively demanding permanent employment due to their employment contracts being partly managed by non-government organisations (NGOs) managements; they were fearful of being recalled from the government programme. After the study ended, during the height of COVID-19 in 2020, when the need for motivated and effective CHWs became much more obvious to decision makers, the semi-urban-based teams received permanent employment with remuneration between R9-11,000 (500-600 USD). The task team and their protests raised awareness of the plight of the CHWs, and joining a formal union enabled them to negotiate a modest salary increase. However, it was the emergency created by the world-wide COVID-19 pandemic that forced decision-makers to acknowledge their reliance on this community-based cadre. Hopefully this recognition, and the associated gains, will not fade as the pandemic recedes.
{"title":"Mobilisation towards formal employment in the healthcare system: A qualitative study of community health workers in South Africa","authors":"Hlologelo Malatji, Frances Griffiths, Jane Goudge","doi":"10.1101/2023.07.11.23292526","DOIUrl":"https://doi.org/10.1101/2023.07.11.23292526","url":null,"abstract":"In low and middle-income countries (LMICs), community health workers (CHWs) play a critical role in delivering primary health care (PHC) services to vulnerable populations. In these settings, they often receive low stipends, function with a lack of basic resources and have little bargaining power with which to demand better working conditions. In this article, we examine CHWs’ employment status, their struggle for recognition as health workers, and their activities to establish labour representation in South Africa. Using a case study approach, we studied seven CHW teams located in semi-urban and rural areas of Gauteng and Mpumalanga Provinces, South Africa. We used in-depth interviews, focus group discussions and observations to gather data from CHWs and their representatives, supervisors and PHC facility staff members. The rural and semi-urban sites CHWs were poorly supervised, resourced and received meagre remuneration, their employment outsourced, without employment benefits and protection. The lack of career progression opportunities demotivated the CHWs, particularly those keen to establish a career in health. In the semi-urban sites, CHWs established a task team to represent them that held regular meetings and often used violent and disruptive strategies against clinic, district and provincial management, which often led to tensions and conflicts with facility staff and programme coordinators. After a meeting with the local provincial legislature, the task team joined a labour union (NEHAWU) in order to be able to participate in the local Bargaining Council. Though they were not successful in getting the government to provide permanent employment, the union negotiated an increase in stipend from R2 500 (136 USD) to R3 500 (192 USD). In contrast, in the rural sites, the CHWs were not actively demanding permanent employment due to their employment contracts being partly managed by non-government organisations (NGOs) managements; they were fearful of being recalled from the government programme. After the study ended, during the height of COVID-19 in 2020, when the need for motivated and effective CHWs became much more obvious to decision makers, the semi-urban-based teams received permanent employment with remuneration between R9-11,000 (500-600 USD). The task team and their protests raised awareness of the plight of the CHWs, and joining a formal union enabled them to negotiate a modest salary increase. However, it was the emergency created by the world-wide COVID-19 pandemic that forced decision-makers to acknowledge their reliance on this community-based cadre. Hopefully this recognition, and the associated gains, will not fade as the pandemic recedes.","PeriodicalId":501386,"journal":{"name":"medRxiv - Health Policy","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-07-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138526824","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Objectives: In recent years, to enhance access to and use of health care the government of Ethiopia has introduced voluntary Community Based Health Insurance (CBHI) schemes for the rural and informal sectors of the economy. After years of planning and the ratification of a legal framework the government proposes to introduce a compulsory Social Health Insurance (SHI) program for formal sector employees. The proposed scheme will provide access to contracted health care facilities at a premium of 3% of the gross monthly income of employees with another 3% coming from the employer. While several studies have examined the willingness to pay this premium, little is known about the health care seeking behaviour (HSB) of formal sector employees. In part, the implementation of the SHI has been delayed due to the unwillingness of public servants to pay the proposed premium. Scheme coverage which will be restricted to contracted facilities, may also be contentious if this is dominated by publicly provided health care services. This paper investigates both, the determinants of health care seeking behaviour of formal sector employees and their families and attitudes related to the introduction of SHI such as fairness, affordability, and willingness to pay the SHI premium. Through these explorations, the paper sheds light on the potential challenges for the implementation of SHI. Setting: The study is based on a survey of formal sector employees and their families in urban Ethiopia. It covers the major administrative regions of the country and contains information on 2,749 formal sector employees and their families or a total of 6,894 individuals. Results: Regarding outpatient care, conditional on falling ill, 85.5% sought some form of care within a couple of days (2.4 days) of falling ill. The bulk (94%) of those who did seek care, opted for formal treatment. A majority of the visits (55.9%) were to private health clinics or hospitals. In the case of inpatient care, the picture was reversed with a majority of health care seekers visiting public sector hospitals (62.5%). There is a strong positive link between income and the use of private health services. A majority of the sample (67%) supported the introduction of SHI but only about 24% were willing to pay a premium of 3% of their gross monthly income. The average WTP was 1.6%. Respondents in the two richest income quintiles were far more likely to oppose SHI and consider it unfair. Conclusion: The prominent role of the private sector especially in terms of outpatient care and the stronger resistance to SHI amongst the two richest income quintiles, that is, those who are most likely to use private health care providers, suggests that the SHI program needs to actively include private health care facilities within its ambit. Additionally, as was done prior to the introduction of the CBHI, concerted efforts at enhancing the quality of care available at public health facilities, both, in terms of perception and
{"title":"The Introduction of Social Health Insurance and Health Care Seeking Behavior in Urban Ethiopia","authors":"Zahra Zarepour, Anagaw Mebratie, Dessalegn Shamebo, Zemzem Shigute, Getnet Alemu, Arjun Singh Bedi","doi":"10.1101/2023.07.05.23292262","DOIUrl":"https://doi.org/10.1101/2023.07.05.23292262","url":null,"abstract":"Objectives: In recent years, to enhance access to and use of health care the government of Ethiopia has introduced voluntary Community Based Health Insurance (CBHI) schemes for the rural and informal sectors of the economy. After years of planning and the ratification of a legal framework the government proposes to introduce a compulsory Social Health Insurance (SHI) program for formal sector employees. The proposed scheme will provide access to contracted health care facilities at a premium of 3% of the gross monthly income of employees with another 3% coming from the employer. While several studies have examined the willingness to pay this premium, little is known about the health care seeking behaviour (HSB) of formal sector employees. In part, the implementation of the SHI has been delayed due to the unwillingness of public servants to pay the proposed premium. Scheme coverage which will be restricted to contracted facilities, may also be contentious if this is dominated by publicly provided health care services. This paper investigates both, the determinants of health care seeking behaviour of formal sector employees and their families and attitudes related to the introduction of SHI such as fairness, affordability, and willingness to pay the SHI premium. Through these explorations, the paper sheds light on the potential challenges for the implementation of SHI. Setting: The study is based on a survey of formal sector employees and their families in urban Ethiopia. It covers the major administrative regions of the country and contains information on 2,749 formal sector employees and their families or a total of 6,894 individuals.\u0000Results: Regarding outpatient care, conditional on falling ill, 85.5% sought some form of care within a couple of days (2.4 days) of falling ill. The bulk (94%) of those who did seek care, opted for formal treatment. A majority of the visits (55.9%) were to private health clinics or hospitals. In the case of inpatient care, the picture was reversed with a majority of health care seekers visiting public sector hospitals (62.5%). There is a strong positive link between income and the use of private health services. A majority of the sample (67%) supported the introduction of SHI but only about 24% were willing to pay a premium of 3% of their gross monthly income. The average WTP was 1.6%. Respondents in the two richest income quintiles were far more likely to oppose SHI and consider it unfair. Conclusion: The prominent role of the private sector especially in terms of outpatient care and the stronger resistance to SHI amongst the two richest income quintiles, that is, those who are most likely to use private health care providers, suggests that the SHI program needs to actively include private health care facilities within its ambit. Additionally, as was done prior to the introduction of the CBHI, concerted efforts at enhancing the quality of care available at public health facilities, both, in terms of perception and","PeriodicalId":501386,"journal":{"name":"medRxiv - Health Policy","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-07-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138526918","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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