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Willingness to PayFor Social Health

Insurance RMG Sector Workers

Source:

Schedule

•Project Background

•Survey Design

•Snapshot of Key Findings

2

Objectives

Conduct a Willingness-to-pay (WTP) study in order to:

Gauge the feasibility of rolling out a SHI scheme for the RMG sector;

Identify measures to increase acceptance of SHI in the sector

Specific tasks:

Design hypothetical SHI scheme;

Elicit responses regarding the WTP from the RMG workers and employers, following appropriate sensitization;

Identify socio-economic and other determinants of WTJ/WTP.

Source:

Schedule

4

•Project Background

•Survey Design

•Snapshot of Key Findings

Survey Design

The study was conducted using a quantitative approach with a stratified multistage random sampling model. Interviews were conducted face to face.

The target respondents were RMG workers (both male and female) as well as higher officials in the factories.

The sample size of workers was 600 workers. The sample size was determined after considering 95% CI, 5% error level, 1.5 de and 10% non-response rate.

n = Z2p (1-p)d2

Based on the database of Department of Inspection for Factories and Establishments (DIFE), 99% of the garment factories are in Dhaka, Gazipur, Chittagong and Narayanganj. Therefore our survey was conducted in these four areas.

The sample was also stratified by factory size and whether it was a member of BKMEA or BGMEA.

Sample Distribution

A total of 60 factories were visited to take interviews of 600 workers.

90 workers were interviewed in the community as they were busy working while at the factory.

Workers were selected randomly from the attendance register.

From each factory two higher officials (management staff) were interviewed. Thus the sample size of management segment was 120.

The sample size of

each center and

trade body was

proportionate to the

total worker number

found in the DIFE

database for each

center and trade

body

470

130

BGMEA

BKMEA

250

8050

220

Dhaka

Chittagong

Narayanganj

Gazipur

Demographic Information

34.7%

65.3%

Gender Profile

MaleFemale

18-25 years 26-35 years 35+ years0

10

20

30

40

50

60

70

80 70.5%

24.2%

5.3%

Age Profile

Per

cent

age

Single Married Divorced Widowed0

10

20

30

40

50

60

70

37.3%

61.5%

0.5% 0.7%

Marital Status

20.5%

27.5%

14.7%

37.3%

Family Status

None

One child

Two or more children

Unmarried

Sensitization

Why did we design and conduct a sensitization session?

The concept of social health insurance in Bangladesh is new.

Limited information and understanding about the concept

Raise awareness of benefits of SHI amongst workers and its functional modalities

Sensitization: what was done?

A sensitization session was conducted before asking questions in each factory. The length of the session was about 15-20 minutes.

The session comprised:

Showing a video

A video clip was shown to the respondents to illustrate how health episodes can be unpredictable and how a health protection can be helpful

Introduction and playing a game to explain concept of SHI

Feedback session to check the workers have understood the scheme.

 

WTP assessed using bidding process

Willingness to Pay (WTP) methodologies are used to help determine the best price in many social sectors including health..

An open-ended WTP question simply asks the respondents to give a monetary value.

However a major drawback is that the responses are skewed towards either a zero value (protest bid) or a very high value.

The bidding game is a set of prices as starting point.

Evidence suggests that this bidding process tends to be superior at eliciting “real” responses.

A potential drawback is that bidding can be affected by the starting value (anchoring bias). For this reason the study used multiple starting points.

Bidding Explanation

250

500(2x)

125

188 63750(1/2x)

250

Starting point for cost of benefit package

Benefit Package: Inpatient care

Note: Benefit Package designed via joint consultation

A worker and other family members (spouse + any number of unmarried children below 18 years) can get hospital treatment (at a clinic close to respondent’s factory).

The maximum reimbursement for a family is 200,000 BDT annually.

This includes all ancillary hospital costs, that is: bed rate, medicines, and laboratory tests.

However, except in case of emergencies, workers can go to the hospital only if the general practitioner – the first point of entry and so called ‘gatekeeper’ – refers them to the hospital.

  

Benefit Package: Outpatient care

General Practitioner (GP): An unlimited number of visits. The GP will serve as a gatekeeper, with a referral system put in place.

Specialist Doctor: Upon referral from the general doctor, the family can avail of

specialist services 3 times a year.

For medicines, the scheme will give worker’s family up to 3000 BDT per year with 20% co-payment. This does not include medicines that are commonly prescribed (e.g. Paracetamol, generic antibiotics, etc.). A negative list will be drawn up.

For lab tests (X-ray, blood test, etc.), you will receive up to 3000 BDT per year (in total) – again with a 20% copayment.

Workers will not receive any cash. This is the total receivable for all members as part of one policy (spouse + any number of unmarried children under 18 years).

Benefit Package: Enrollment and payment explained

To be part of this scheme, workers will have to pay a premium on a monthly basis.

This will be taken out from their salary, but will provide them and their family with health services as described previously.

They pay some amount, and the remaining amount will be paid by their employer.

Study Limitations

Limited time for sensitization;

Response bias due to congested environment in which the interviews were taken;

Presence of management authorities could affect response in some cases.

DIFE list was used- and we’re not certain how up to date this is.

We were forced to rely on workers’ estimates/recollections of their household income, saving and monthly medical expenses.

Small sample size for management (120).

Source:

Schedule

16

•Project Background

• Introduction of study team

•Snapshot of Key Findings

Willingness to pay per month

When workers were asked what they would pay (thinking about heir salaries), the mean value of the responses is BDT 83.6. This corresponds with the value derived from the responses they gave during WTP bidding part (BDT 82.7).

The median values are lower at BDT 63 (salary) and BDT 50 (WTP) respectively.

Up to 50 Taka

Taka 50 - 100

Taka 100 - 150

Taka over 150

Will not participate

0

5

10

15

20

25

30

35

40

45

50

Willingness to Pay (% Respondents)

The respondents were asked to express the desired amount that they will spend to join in the scheme based on their salary and savings.

AverageWorkers’ Monthly Claimed Saving 1,139Workers’ Monthly Claimed Household Income

11,185

Experience of IllnessAmong the interviewed respondents 40.7% workers have fallen sick at least once in last 3 months. 37.9% said that someone from their family members suffered from sickness.

Pharmacy

Local clinic (private/ NGO)

Government hospital

61.1

16.4

9.8

54.5

28.1

15.2

Health Provider Usage

For Fam-ily

Worker

OwnBase: 600

91

112

SpouseBase: 376

111

110

OffspringBase: 253

103

98

Monthly Medical Expenses (in BDT)

Spend on Medicine

Spend on Doctor

9.8% of workers go to factory health facilities as well

Among those who have fallen sick

Willingness to Join the SHI Scheme

Most of the workers were willing to purchase insurance but BKMEA’s workers showed greater interest.

No strong association between willingness to join SHI scheme and different demographic characteristics has been found.

However, a test of independence suggests that willingness to join and trade body are dependent or have some association. (the sig. value of <.5(0.001))

All BKMEA Workers BGMEA Workers0

10

20

30

40

50

60

70

80

90

100

84.3% 93.1% 81.9%

15.7%6.90000000

000001% 18.1%

Willingness to Join

Willing Unwilling

Understanding of SHI Scheme (post-sensitisation)

Overall, most of the workers absorbed the concept of insurance after the sensitization process.The most common misconception was that they would be able to reclaim insurance premiums if they did not need health treatment.This was particularly prevalent in Chittagong where 47% of workers thought they could claim back money if they did not pursue treatment.

All BKMEA Workers BGMEA Workers0

10

20

30

40

50

60

70

80

90

100

87% 90% 86.2%

13% 10% 13.8%

Comprehension of SHI Scheme

Understood Did not understand

Motivations to join an SHI scheme

The main motivation behind the willingness to participate in SHI scheme is the assurance of the low cost healthcare. However, there is also evidence of solidarity as a motivation.

Low cost healthcare

To help others

Own and Family Health Security

Facing health problems frequently

Others

87.5

58.9

57.1

17.6

1.6

Reason for the Willingness (in%)

Reasons for not wanting to join the SHI Scheme

Lack of trust in the insurance scheme was the most common reason for rejection.

Among those who rejected the scheme (Base:94)

68.1

40.4

37.2

29.8

25.5

Don't trust insurance

Will pay as required

Do not want to pay in advance

Not my decision (husband/wife needs to decide)

Lack of money

Reason for the Rejection (in%)

Mistrust of insurance is much higher among female (76.3%) workers than male workers (54.3%)

Readiness to Lend Money to Colleagues when they fall sick

23

Most of the respondents would loan their colleagues money if they became sick. Male workers are prepared to loan more money than female workers.

97.7%

2.3%

Will Lend Money to Colleagues

Yes No

Average intended amount of lending is BDT 522 however this amount differs between male (BDT 597) and female

(BDT 482)

Availability of Health Facilities in Factory

More than 85% of factories have in-house health-care facilities. And 96% of workers in those factories have said they use these facilities.

85.7%

14.3%

Have health facilities in factory

Yes No

95.7% Can visit the facility during working hour

There were no claims that the factory authority would deduct salary if the workers use emergency treatment during working hours.

Barriers to Accessing Health Facilities

Expense of treatment is the biggest barrier for the workers. Lack of health-care facilities nearby and lack of confidence in quality of the health care services are also significant factors.Barriers were higher for family members’ treatment. This may be because family members are not allowed to use factory based treatment facilities.

Treatment too Expensive

No Nearby Health Facility

Don’t trust quality of care received

Lack of Money

0

5

10

15

20

25

30

35

40

45

50

35.7%

46.8%

32.7%

46%

32% 34.2%

14.3%12%

Barriers to Accessing Treatment (%)

Personal

For Family

Willingness to Join in SHI Scheme (Management)

26

Just over half of the management employees interviewed felt that their companies would like to be part of the SHI scheme

The average monthly premium that management is willing to pay is BDT 74 and the Median is BDT 30.

54%46%

Yes No

Expected Benefit and Willingness to continue

27

More than half of the management employees expected that joining the scheme would impress foreign buyers and lead to increased order.

However, the majority of the respondents would continue the scheme even if they did not see an increase in orders.

55%45%

Expected Benefit for company’s Business

Yes No

68%

32%

Willingness to Continue

Yes No

Recommendations about SHI Scheme from Employees

28

Inclusion of all family members (especially parents) was the most common additional recommendation.

No opinion

Others

Quality health facility should be arranged

Nothing needs to be changed

If the skim is of 50 BDT

If the money is refunded

If the amount is less

Covering all family members

31.0%

17.0%

3.5%

3.7%

4.8%

6.8%

13.5%

25.0%

Workers’ Expectations of Employer Contribution

47.7

27.0

11.2

6.73.5

Expected Owner's Contribution (in%)50%

75%

100%

80%

60%

As owner's willingness

As par affordability

Double of employees' share

No Comment

Almost half of the employees think that the authority should contribute equally with the workers for the SHI Scheme.

Policy Implications

Whilst workers showed a strong understanding of most aspects of SHI, a Communication strategy is needed to ensure full comprehension:

That insurance is non-refundable;

That there will be cost-sharing between workers and employer. “Trust” is crucial to the scheme’s viability, particularly for female workers.

The premium value set for SHI needs to be re-visited. Workers monthly contribution should be between 50-80 taka plus a matching share from employer.

Health facilities in factory premises should be leveraged to cover primary care. This will allow the scheme to focus on curative care and specialized treatment.

Gazipur and Naryanganj had higher median WTP. This could mean that they are better choices for pilot sites.

Some factories showed a high WTP. These might also be good pilot sites.

Thank You!

Source: 31