Willingness to pay for social health insurance and associated social

vulnerability in informal sector workers, Khartoum, Sudan: A contingent

valuation method

With all authors contact detail

Mahmoud Ali Fadlallah
Disaster Preparedness, Mitigation and Management (DPMM)
Asian Institute of Technology (AIT)
P.O. Box 4, Klong Luang, Pathumthani 12120, Thailand
Public Health Institute (PHI), P.O. Box, 9099, Alsahafa, Khartoum, Sudan
Tel: +66-623830151
Email: mahmoud.ali2000@outlook.com
Dr. Muna Hassan Mustafa
Directorate of Public Health, Directorate General of Health Affairs, Riyadh Area, Kingdom of
Saudi Arabia
Tel: +966-564270052
Email: mhmhs67@hotmail.com
Dr. Indrajit Pal
Disaster Preparedness, Mitigation and Management (DPMM)
Asian Institute of Technology (AIT)
P.O. Box 4, Klong Luang, Pathumthani 12120, Thailand
Tel: +66-2-5246428, Mobile: +66-824864052
Email: indrajit-pal@ait.asia, indrajit.pal@gmail.com
Abstract
Background: This study is intended to analyze willingness to pay (WTP) for Social Health
Insurance (SHI) and social vulnerability among the population of informal sector with a special
focus on maximum WTP. Most of the studies carried out, so far, in health insurance in Sudan did
not address the importance of informal sector which hindered the achievement of universal
health coverage (UHC). Informal sector represents a large segment in the labour market in
Sudan. Sudan is ranked as a low-income country and the poverty rate is quite high (46.5%) with
significant variation among states, Khartoum state is 26% (Sudan CBS, 2010; The World Bank,
2011).
Methods: Data was collected through a cross-sectional survey using a two-stage cluster
sampling scheme. An administered questionnaire had been delivered to (623) household heads or
representatives. A contingent valuation method (bidding game) was used to elicit WTP.
Respondents received a detailed description on service package of social health insurance (SHI).
Chi-square analysis was conducted to identify factors associated with WTP while ordinal
regression performed to explore factors influencing maximum WTP.
Results: Overall, 34% (211) of the respondents were willing to pay for SHI at the offered bids,
of whom 22% (136) were willing to pay the first bid (40 SDG) whereas 15.4% (75) of the
remaining respondents were willing to pay the second reduced bid of (30 SDG). Income,
education, occupation, residence, medical spending, previous insurance status, type of nearest
health facility and type of transportation means to attend health services were positively
associated with willingness to pay at various levels.
Conclusion: Socioeconomic factors, place of residence, type of nearest health facility and
transportation means to attend health services were the main influencers of the maximum
willingness to pay. This complied with similar studies conducted in other developing countries.
Examining social vulnerability of informal sector workers will give profound understanding and
insight on the enrolment behavior. These findings have policy implications on achieving
universal health coverage and guiding a successful enrolment and sustainability of the informal
workers in SHI.
Key words: Willingness to pay, Social Health Insurance, Informal Sector, Contingent valuation,
Social Vulnerability

Acknowledgement
We would like to thank; Public Health Institute, Sudan; Asian Institute of Technology, Thailand;
Social Health Insurance, Khartoum State, Sudan for their kind support and guidance to develop
and implement the study as well as drafting the final report. Special thanks to those who
cooperated in data collection from the field as well as those who participated in data analysis.

Funding source for the study or project if any

The authors would like to thank Social Health Insurance, Khartoum State for funding the study
under the universal coverage program to address the informal sector workers.

Introduction
Sudan is a low-income country and is highly considered as vulnerable to the global recession.
The country indicators are among the poorest in the world. In 2015, the UNDP report revealed
that the Human development index (HDI) was 0.490 and the country ranked 165th out of 188 in
the world (UNDP, 2016). The incidence of poverty is high (46.5%) and there is a considerable
variation in poverty levels between and within the states (Sudan CBS, 2010). While there is
53.1% of the population are in multidimensional poverty (MP) there is 31.9% are in severe MP.
The national multidimensional poverty index (MPI) is 0.290 (UNDP, 2016).
Economic activity depends largely on agriculture, which provides livelihood to about 70 % of
the population, contributing to 37 % of Gross Domestic Product (GDP) and 15 % of total export
earnings. Non-oil growth is driven by the service sector which remains underdeveloped and
vulnerable to reduced public consumption, inadequate government support, and low external
investment (MoH Sudan, 2008).
The country remains highly subjected to protracted civil war, political instability, and natural
disasters which threatened the economic growth and impacted the health of the population. Oil
production has become an important source of government revenues contributing to about 50
percent of the government budget. However, after separation of South Sudan country, Sudan
became with low economy profile and the long-standing sanctions affected its population and
stunted the overall development (MoH Sudan, 2008). As a result, large number of population
shifted towards informal business in terms of agriculture, construction, and retail sectors.
The current health care financing system has not been able to protect people from financial
catastrophe and even pushed them further to poverty. The government health spending as part of
total health expenditure (THE) has decreased from 28.9% in 2008 to 22.34% in 2011 because of
decreased public share, even though the (THE) increased by 15% compared to in 2008. In 2011,
the general government health expenditure (GGHE) as percentage of the general government
expenditure (GGE) was 8.23% which is far below the Abuja commitment of 15%. However,
such expenditure was higher by over 15% in 2011 compared to that in 2008 (MoH Sudan, 2011,
2014). The social health insurance spending as percentage of (THE) was about 4.1% and
equivalent to 18.29% of GGHE. The percentage of households experiencing catastrophic
expenditure and the households impoverished due to out of pocket (OOP) expenditure on health
has increased from 64% in 2008 to 70% in 2011 (MoH Sudan, 2008, 2011).
Healthcare financing is an essential component of universal health coverage. In low- and middle-
income countries funding healthcare for informal sector workers has shown to be a big
challenge. Indirect taxes have emerged as a source of funding healthcare for these workers (Khan
& Ahmed, 2013). To achieve universal health coverage through pooling risk to the greatest
extent possible, user fees and other out-of-pocket payments must be reduced and the level of
prepayment should be increased in a way that maximizes the size of risk pool(s). This can be
done by increasing tax funding and/or by introducing mandatory (i.e. social or national) health
insurance (McIntyre et al., 2008).
The social health insurance in Sudan was launched through National Insurance Corporation Act
in 1994, amended in 2001 and subsequently in 2004. As a result, many insurance schemes were
launched including: national health insurance, police services health insurance, armed forces
health insurance. The National Health Insurance Fund (NHIF) has its headquarter in Khartoum.
There is a state health insurance fund in each state and an office in each locality. Khartoum state,
which holds the capital, has a health insurance scheme separated from the NHIF.
The membership of the fund is compulsory for the formal sector, while it is voluntary for the
informal sector and small companies (≤ 10 employees). The subscriber unit is ‘family’ and the
benefit package covers almost all services including, in some cases, even treatment abroad but
the patient must pay 25% of the drug cost irrespective to its nature. In private and public sectors,
the employee pays 4% of his/her salary as a premium and the employer contributes about 6% of
the employee’s salary. The Martyrs’ Fund gives support to the martyrs’ families and the Zakat
Fund (Muslim Charity Fund) pays premiums on behalf of poor families. The Student Support
Fund pays for University students. The independent workers (farmers, advocates etc.) pay a flat
rate of 40 SDG per month (NHIF, 2013).
The financial status of the fund seems unstable due to several reasons and challenges. These are:
limited pool, low level of premium and the amount paid is regressive, fixed co-payment rate for
medicines (25%) does not distinguish between costlier brand-name and cheaper generic drugs,
the extensive non-costed benefit package, delays in paying providers adversely affect the system,
the moral hazard, the informal sectors are hard to maintain their contribution as they prefer to
participate on a selective basis as well as the inadequate enforcement of mandatory registration
(MoH Sudan, 2011a, 2014). Further, the small proportion of formal private sector employees
who contribute to the NHIF during their active working life, their retirees would be
automatically absorbed later into the system (MoH Sudan, 2011a).
The coverage under NHIF reached about 37% of the population with another 5.5% covered by
other health insurance schemes, e.g. police, army, and parastatal organizations. Out of the total
covered, the informal sector represents about 22.5% while the formal sector represents 30.2%.
The private sector, retirees, and social support component represent 1.8%, 4.9%, and 40.5%
respectively. However, there is a significant variation in coverage among the states, for instance:
River Nile (41.2%), South Darfur (11.3%), Khartoum (65%) (NHIF, 2013). The total coverage
of the informal sector in Khartoum state was about (20.3%) of the total insured population.
Though, when the coverage compared to state’s target, it will be reduced to 13.3% only (HICKS,
2014). Due to lack of accurate figure regarding informal sector people in Khartoum state, such
estimation of coverage is based upon the state’s target.
Achieving universal coverage on a national scale by implementing a single national scheme
would be a problematic due to the absence of appropriate administrative infrastructures, lack of
sustainable government fund, and lack of understanding consumer’s preferences (Carrin et al.,
2008). One of the main reasons behind the low coverage of the informal sector is the negative
selectivity where the people chooses to join the insurance only when they get major sickness or
being subjected to a surgical operation. They are very keen to pay their premiums in time to get
the maximum insurance benefits. This can be observed only for couple of months as they
automatically opt-out to avoid continuous payments. In 2014, only 26% were paying regularly to
the scheme (HICKS, 2014). Furthermore, some of the people they don’t trust the insurance
services as they have concerns on the package and/or the quality of services provided (interview
with director of universal coverage directorate). Moreover, the insurance management lacks clear
evidence regarding consumer’s preferences where a suitable policy can be adopted to deal with
such population.
Similar studies conducted in developing countries revealed that the higher the socioeconomic
status (SES) group, the higher the stated WTP amount. Likewise, the urbanites are more WTP
than rural dwellers. Males and people with higher education stated higher WTP values than
females and those with lower education. Previous health care spending was a factor associated
positively with WTP (Onwujekwe et al., 2010).
This paper assessed the household’s WTP for SHI within the stated benefit package and
investigated the factors associated with maximum WTP of the informal workers together with
the links to social vulnerability as a determinant of health. The study has policy implications in
achieving universal health coverage in Khartoum state by applying SHI and attracting informal
sector people to participate.
National perspectives on impact of various hazards on health or impacted
people could be added. Some charts or table.
Table 1: Mortality from RTAs and Major Natural Hazards in Sudan
Major/Frequent Deaths/Year
Hazards 2009 2010 2011 2012 2013
RTAs 2471 2758 2667 2482 2349
Floods 42 33 49 102 118
Epidemics 65 116 147 288 74
Source: Sudan Civil Defense, MoH, Traffic Police Department, 2013
Figure 1: RTAs, Epidemics, and Floods-related Deaths in Sudan, 2005-2013
3000
2758
2667
2431 2471 2482
2500 2349
2227
No. of Deaths

2000 1874
1783

1500

1000

476 430
500 382
288
157 147
5
81 62 65 42 116 49 102 74118
0 3
0
2005 2006 2007 2008 2009 2010 2011 2012 2013
Epidemics Floods RTAs
Source: Sudan Civil Defense, MoH, Traffic Police Department, 2013

Table 2: Major/Frequent Health Hazards by Number of People Affected

Major/Frequent Affected People/Year

Hazards 2005 2006 2007 2008 2009 2010 2011 2012 2013
RTAs 14,459 17,209 21,329 20,346 22,006 23,501 22,203 19,837 19,084
Floods 156,000 150,000 565,335 50,900 111,455 1,065 14,575 135,135 431,250
Epidemics - - - 1,846 2,300 26,296 14,558 11,325 4,396
Source: Sudan Civil Defense, MoH, Traffic Police Department, 2013
Figure 2: Major/Frequent Health Hazards by Number of People Affected
No. of People Affected

600000

500000

400000

300000

200000

100000

0
2005 2006 2007 2008 2009 2010 2011 2012 2013

Source: Sudan Civil Defense, MoH, Traffic Police Department, 2013

Tabular data to show how the informal sector population increased over time
impacting the increased vulnerability as additional drivers.
Figure 3: Projected Informal Sector’s Population in Millions
50
Projected Pop. No. in Million

45
40
35
30 Projected Inform. Sector Pop. in
Million
25
Projected Insurance Target Popu-
20 lation
15
9.25 9.43 Projected Total Population
8.29 8.54 8.72 8.89
10
5
0
2015 2016 2017 2018 2019 2020
Years

Source: National Health Insurance Fund, 2015

Method and Materials

Study area & hypothesized variables
In 2014, the population of Sudan was estimated at 36,1 million. This estimate is based on 2008
census’s projections. Khartoum state population was estimated at about 6.8 million (CBS, 2008).
Khartoum state is divided into seven localities namely: Khartoum, Omdurman, Bahry, Sherg
AL-nil, Um Badda, Karari, and Jebel Awlia. The state is characterized by the existence of formal
and informal sectors; however, the size of the informal sector is determined based on the target
population provided by the Social Health Insurance Corporation of Khartoum State (Health
Insurance Corporation Khartoum State (HICKS), 2014).
The target population is the informal sector workers in Bahry locality in Khartoum state. The
respondent is the household’s head or representative (informative person) with at least 15 years
of age and currently not a member of any type of health insurance schemes. The idea behind
selecting Bahry locality was that, the locality consists of urban and rural communities with
different social classes that could be used to generalize the results over Khartoum state. We used
the operational definition of informal sector workers that is used by the International Labor
Office (ILO), namely: own-account workers, unpaid family workers, and employers and
employees working in establishments with less than 10 persons engaged (Hussmanns, 1993;
Bärnighausen et al., 2007).
Information was collected on individual characteristics and hypothesized to be factors associated
with or correlated to WTP for health insurance and as explanatory variables in regression
analysis. The followings are the variables among others. Age is considered affecting WTP
because illnesses and morbidity increase as the age increases; Income: Because it leads to
higher demand of all goods and services including SHI (Damschroder et al., 2007); Education:
Because higher educated are considered higher demanding for services; Marital status: It’s
related whether to choose or not to participate in SHI. Married individuals are considered more
willing to pay than single persons; Residence: It can affect the decision of seeking healthcare
services (accessibility) (Onwujekwe et al., 2010); Employment status: It’s assumed to be
associated with higher WTP with those have constant employment than those who are irregularly
employed. Furthermore, people with high medical expenditure in the recent past are likely to be
less healthy and thus willing to pay more than those with past lower medical expenditure. Sex is
also considered an independent variable because some studies found variation among males and
females possibly due to health seeking behavior or decisions to participate. Moreover, there are
other variables studied and found to have direct relation with willingness to pay, table 3 (Adams
et al., 2015; Asenso-Okyereet al., 1997; Bärnighausen et al., 2007; Terashita et al., 2011)
Table (3): Operational Definitions of Explanatory Variables
Variable Definition Scale
Age Age of respondent at time of survey in Categorical
years (age categories)
Sex Sex of participant Categorical
(Male/Female)
Marital status Single/Married/divorced/widowed Categorical
Occupation Current job of participant Categorical
Residence Geographical location Categorical
(Urban/Rural)
Educational level Educational level attained by Categorical
respondent
Income No. Sources of income Categorical
 Insurance experience
Medical spending
Dependents
Chronic medication
Never insured or previously insured Categorical
Medical expenditure in the last 6 Categorical
months (expenditure categories)
Presence of dependents (yes/no) Categorical
On regular medication (yes/no) Categorical

Type of nearest health Type and level of health facility used Categorical
facility for treatment

Transportation means to Public, private car, taxi, rickshaw, on Categorical

attend health services foot

Study Design and WTP Elicitation Model

Descriptive cross-sectional study design was used. The required sample size was determined
using sample size table with 95% confidence interval (CI) and 5% margin of error (The Research
Advisors, 2006). A total sample size of 623 were used for the study, in addition to 11 participants
refused to participate were excluded from the analysis. A two-stage cluster sampling scheme was
used to select the participants. In the first stage, the population stratified into urban and rural to
ensure effective representation of population subgroups and the clusters were chosen according
to the size of population at each stratum. That is, 12 clusters (60 %) for urban and 9 clusters
(40%) for rural population. After preparing the list of blocks from the census, Probability
Proportional to Size method was used to randomly select the clusters within the urban and rural
populations. At the second stage and within each cluster, the 30 households were chosen by
using systematic random sampling (SRS). The popular committee provided a list of all eligible
households in their respective blocks. This list saved the efforts in searching for the targeted
households. That is, households were selected only from such list using systematic random
sampling. The total number of eligible households at each block was counted and then divided
by 30 to get the sample interval. The first household was selected by drawing a number from the
sampling interval. Certain eligible households within certain blocks were not completing up to
30 so that other eligible households from the nearest (adjacent) block were chosen to complete
up to 30 using the same method (Lwanga S.K. & Lemeshow S., 1991).
WTP data was collected through a household survey. The contingent valuation method (bidding
game) was used to assess the WTP for SHI among informal sector workers in Khartoum state.
WTP technique is widely used as a method of evaluating health care services and technologies
(Frew et al., 2004; Klose, 1999). Such technique allows the subject to identify a monetary value
for benefits perceived to get through specific intervention (s). A number of economists elicit
willingness to pay for healthcare interventions by using contingent valuation surveys, therefore,
such interventions and its associated benefits can be evaluated in monetary terms (Damschroder
et al., 2007). Survey methodology of WTP has several benefits such as; it’s simple and the direct
estimation techniques can be applied by any research unit, clients without formal education can
answer hypothetical price questions, and their answers are usually internally consistent, WTP
estimates are sensitive to subject characteristics or socioeconomic status, and the information
provided by WTP surveys improves the accuracy of predicting responses to price change (Foreit
& Foreit, 2004).
Further, many previous studies used contingent valuation to measure the WTP for health
insurance in developed and developing countries (Terashita et al., 2011). Researchers from
Taiwan, Japan, China, and India investigated WTP for social health insurance, some of them
targeted the informal sector. They concluded that, the result of the WTP was helpful in decision
making of health policies because the contingent valuation method is a referendum-like. It is
very significant for health policy in that it respects the will of residents (Lang & Lai, 2008;
Terashita et al., 2011). Furthermore, they compared WTP by difference in occupation and
showed that, the association of occupation affected it with the income provided (Bärnighausen et
al., 2007; Terashita et al., 2011). Moreover, they found that, participants’ income, education, and
sex affected their WTP (Dror et al., 2007; Terashita et al., 2011). In this study, a dichotomous
choice elicitation method was used. This format was basically derived to increase statistical
efficiency (Damschroder et al., 2007).
The respondents presented with complete description of the SHI benefit package and the general
entitlements of the insured person. The respondent asked if he/she was willing to pay the first bid
of (40 SDGs1) as a monthly premium for SHI. We used (40 SDGs) as starting bid because it was
the flat rate that applied by the SHI for voluntary participation. If the respondents answered
“yes” to the first bid, then we presented a second higher bid of (50 SDGs). No matter the answer

1
USD 1 = 6 SDG (Exchange rate of 2014)
(yes/no), the respondent must mention later the maximum amount he/she was willing to pay. If
the respondent answered “no” to the initial bid, then we suggested a second lower bid of (30
SDGs). No matter the answer (yes/no), the respondent must mention later the maximum amount
he/she was willing to pay, figure 4.
Data collection and analysis tools
In this study, the contingent valuation method - bidding game model- was used to elicit
willingness to pay through a household survey. A pretested and validated questionnaire with
distinctive parts was used to collect the data. The questionnaire was translated into
understandable local Arabic language to facilitate communication and delivery of questions. A
manual guide was developed for data collectors to ensure full understanding of questionnaire
questions and what they are intended for.
The first part of the questionnaire described the purpose of the study and explained to
respondents whether they consent to participate. The second part comprised of questions
regarding demographic and individual characteristics. Participants' characteristics and
identifications had been maintained throughout the study. The third part included two sections:
the first section described the social health insurance to study participants and its associated
benefits (hospital, outpatient, and emergency care), as well as the proposed premium
contributions. The second section included the willingness to pay eliciting questions using the
bidding game model.
Analysis of factors associated with WTP was performed using Chi-square test (Lang & Lai,
2008; O’Riordan et al., 2008). Only factors that showed evidence of significance in the
univariate analysis were included in the multivariate analysis (ordinal regression with
significance level set at 5% (p value < 0.05) to explore factors influencing WTP. In the same
context, social vulnerability concept would be discussed in line with health insurance as a risk
transfer mechanism. The current research findings were examined and linked to social
vulnerability of informal sector workers.
Limitations of the study
The most evident limitation of the study was the missing qualitative part, as it was required to
complement the quantitative one and to get in-depth knowledge about understanding consumer’s
preferences and the enrolment behavior of the informal sector to the SHI. Bidding game may be
accompanied by estimation bias where the respondents’ answers are influenced by the first
numbers presented in the bidding game (Drummand et al., 2015) . In contrast, many studies
conducted in low and middle-income countries used the same method but showed no starting
point bias (Khan & Ahmed, 2013). In this study, we used the 2014 flat rate applied by the SHI
for the informal sector workers.

Results and Discussion

Six hundred and thirty-four (634) participants were eligible for the study, of which 11 (1.7%)
eligible subjects they refused to participate. The study collected data from 623 respondents in
Khartoum North of Sudan. The respondents surveyed were stratified into urban and rural in an
approximate ratio of (6:4) based on the size of the population at each stratum. Table 2 shows the
frequency distribution and chi-square test results of the explanatory variables under study. Soon
after, ordinal regression performed to expedite the factors associated with the WTP for SHI.
The initial results revealed that, of the entire respondents, there were 211 (34%) respondents
willing to pay for at least the second lower bid of (30 SDGs). In other words, twenty two percent
of the respondents were willing to pay the first bid in addition to 12% who were willing to pay
the second lower bid, i.e. 25% reduction in the bid resulted in more respondents were willing to
pay, figure 4.
Figure (4): Summary Description of The Dichotomous Choice Questions of WTP

In terms of maximum WTP, the average value was (28 SDG), which was lower than the flat rate
stated by SHI for informal sector workers. However, 199 (32.0%) respondents had stated zero
 value. Moreover, 110 (17.6%) respondents were willing to pay less than 20 SDG whereas 9
(1.4%) respondents were willing to pay higher than 60 SDG.
The initial results of chi square revealed that, many factors were found statistically significant in
relation to bid offered including the maximum WTP stated by respondents, table 2.

Table (4): Frequency distribution and Chi2 analysis of the WTP (n=623)
Background Frequencies Chi2 for WTP P value
Information 40 50 30 Max. 40 50 30 Max.
Age/years
30=> 179 (28.7%)
31-45 250 (40.1%) 2.96 4.47 .278 24.36 0.399 0.215 0.964 0.441
46-60 142 (22.8%)
60< 52 (8.4%)
Residence
Urban 361 (57.9%) 23.75 1.28 3.38 28.41 0.000 0.000 0.000 0.000
Rural 262 (42.1%) * * * *
Gender
Male 392 (63.9%) 0.08 2.17 1.83 11.72 0.774 0.330 0.401 0.164
Female 231 (37.1%)
Previous
Insurance
Experience
Never had 557 (89.4%) 8.336 .067 4.78 13.19 0.004 0.769 0.029 0.004
insurance * * *
experience 66 (10.6%)
Previously had
Education
Khalwa only ** 31 (5.0%)
Primary 165 (26.5%)
Secondary 242 (38.84%) 66.42 8.65 11.91 86.98 0.000 0.124 0.036 0.000
University 131 (21.0%) * * *
Postgraduate 10 (1.6%)
Never attended 44 (7.1%)
Marital status
Unmarried 82 (13.2%)
Married 478 (76.7%) 3.65 5.538 12.91 35.34 0.302 0.136 0.005 0.063
Separated/Divorced 32 (5.1%) *
Widowed 31 (5.0%)
Occupation 72.19 3.61 25.74 101.54 0.607
Employee with 0.000 0.000 0.000
salary 83 (13.3%) * * *
Worker with salary 82 (13.2%)
Daily worker/earner 168 (27.0%)
Own a business 93 (14.9%)
Other 106 (17.0%)
Not working 91 (14.6%)
Income sources
Have no source 5 (0.8%)
Have one source 515 (82.7%) 9.22 .78 16.27 26.27 0.010 0.377 0.000 0.000
Have more than one 103 (16.5) * * *
source
Presence of
Dependents
Yes 226 (36.3%) 1.79 .15 4.88 9.53 0.182 .695 0.027 0.300
No 397 (63.7%) *
Previous Medical
spending (SDG)
No spending 134 (21.5%)
285 (45.7%) 17.26 1.67 8.82 27.76 0.001 0.644 0.032 0.001
> 100 * * *
100> ─ 200 153 (24.6%)
200 + 51 (8.2%)
Chronic
medication
Yes 238 (38.0%)
No 385 (62.0%) 0.99 1.12 0.01 2.12 0.320 0.290 0.915 0.549
Distance travelled
to attend health
facility 0.000 0.002
2.70 15.22 2.92 20.83 0.259 0.233
> 5 km 294 (47.2%)
* *
5-10 km 211 (33.9%)
< 10 km 118 (18.9%)
Transportation
means
Public transport 318 (51.0%)
Private car 45 (7.2%) 22.62 10.79 5.43 38.84 0.000 0.029 0.246 0.000
Taxi 64 (10.3%) * * *
Rickshaw 64 (10.3%)
On foot 132 (21.2%)
Type of nearest
health facility for
consultation 363 (58.3%)
Public hospital 24 (3.9%)
Private hospital 141 (22.6%)
Public HC 65 (10.4%) 28.37 4.57 7.86 40.81 0.000 0.334 0.248 0.002
Private HC 26 (4.2%) * *
Private clinic 1 (0.2%)
Traditional healer 3 (0.5%)
Other
* →Statistically significant (p value < 0.05) ** → Type of informal education

Ordinal regression was performed to show the influence of factors on maximum WTP. Only nine
factors showed evidence of significance in Chi-square test and therefore included in the
regression analysis. Maximum WTP values were grouped into four sub-categories and the
analysis performed accordingly.
The variables that showed evidence of statistical significance (nine variables) were then included
in an ordinal regression model to explore more about their influence on maximum WTP, table 3.
By default, ordinal regression uses the last category as a reference for each variable. The model
produced was fair and can explain the significant variation observed in the stated maximum
WTP.
Table 5: Results of ordinal logistic regression
Variable Estimate (Std. P value 95% Confidence Interval
Error) Lower Bound Upper Bound
Previous Insurance
Experience:

Never had =1 .957 (.393) .015 .187 1.727

Previously had =2 0a
Residence:

Urban =1 .770 (.234) .001 .312 1.228

Rural =2 0a
Education:

Khalwa =1 1.286 .095 -.222 2.795

Primary =2 1.181 .081 -.145 2.507
Secondary =3 1.579 .017 .281 2.877
University =4 2.203 .001 .872 3.533
Post-graduate =5 .540 .580 -1.371 2.451
No formal education =6 0a
Occupation:

Emp. with salary =1 1.105 (.373) .003 .373 1.837

Worker with salary =2 .425 (.357) .234 -.275 1.125
Daily worker =3 -.367 (.363) .312 -1.078 .345
Business owner =4 .770 (.346) .026 .093 1.448
Other =5 .629 (.361) .082 -.079 1.337
Doesn’t work =6 0a

Income sources:
 Have no source =0 -1.396 (1.223) .254 -3.793 1.001
Have one source =1 -.892 (.245) .000 -1.371 -.413
Have < two sources =2 0a
Medical spending (SDG):

No spending =0 -.234 (.392) .551 -1.002 .534

100 > =1 -.082 (.332) .805 -.733 .569
100 to > 200 =2 .127 (.346) .714 -.552 .805
200 + =3 0a
Type of nearest health
facility for consultation:

Public hospital =1 17.382 (.456) .000 16.489 18.275

Private hospital=2 18.070 (.566) .000 16.960 19.180
Public health center =3 17.754 (.483) .000 16.808 18.700
Private health center =4 17.835 (.531) .000 16.794 18.876
Private clinic =5 18.096 (.000) . 18.096 18.096
Traditional healer =6 1.441 (9295.46) 1.000 -18217.333 18220.214
Other= 7 0a
Transportation means:

Public transport =1 .391 (.317) .217 -.230 1.012

Private car =2 .783 (.479) .102 -.156 1.722
Taxi =3 .888 (.432) .040 .041 1.735
Rickshaw =4 .405 (.344) .239 -.269 1.080
On foot =5 0a
Distance travelled to
attend health facility:

5 > km -.112 (.320) .727 -.739 .516

5-10 km -.162 (.290) .576 -.731 .406
10< km 0a

For health insurance experience as a determinant factor for inclusion in the study and as one of
the explanatory variables, respondents who never had insurance experience were more willing to
pay than those who previously had (p value = .015, CI: 0.187–1.727). Urban population were
more likely willing to pay than the rural (p value = .001, CI: .312–1.228). Furthermore, the
higher amounts of WTP were stated by the urban respondents. Education was a strong
determinant of WTP. The results revealed that respondents having secondary or university
education were more likely willing to pay than those having lower or no formal education with
exception to those having postgraduate degrees (p values = .017, .001; CI: .281–2.877, .872–
3.533 respectively). This complied with the hypothesis that WTP increases as educational level
increases and people become highly demanding for services or goods including the health (Dror
et al., 2007).
Occupation was also a significant determinant of WTP. With reference to unemployed category,
employees with salary, followed by business owners were more likely willing to pay than salary
workers, and daily workers (p value = .003, .026; CI: .373 to 1.837, .093 to 1.448 respectively).
Daily workers mean those who earned on daily basis which is considered as an irregular job and
hence irregular source of income. For instance: construction workers, rickshaw and taxi drivers,
hand crafts etc. This finding is comparable to other findings that compared WTP by difference in
occupation and showed that, the association of occupation affected it with the income provided
(Bärnighausen et al., 2007; Terashita et al., 2011). Therefore, job security together with good
income has direct association with WTP.
Income was a significant determinant of maximum WTP. It’s important to mention that, getting
an accurate estimation of household income was extremely difficult, instead, number of
household income source(s) was used as a factor under study. About 82% of the respondents had
one main source of income. Interestingly, regression model results - more than one source used
as a reference category - revealed that respondents with one source of income were less likely
willing to pay (p = .000; CI: -1.371 to -.413). This means that as number of income sources
increased, the total income increased and respondents’ WTP increased as well. Other studies
showed close findings that WTP was moderately and significantly associated with income
(Bärnighausen et al., 2007; Damschroder et al., 2007; Terashita et al., 2011).
Surprisingly, many studies mentioned that previous medical expenditure was a factor associated
with WTP. But in this study after had been included in the regression model it showed no
evidence of significance. It’s noteworthy that, the median value of medical expenditure was (150
SDG) which is quite high compared to stated flat rate of SHI. Interestingly, accessibility to
healthcare services, based on type of health care facility, was statistically significant with
maximum WTP. Respondents who used private facilities for consultation and treatment or as
referral units were more likely willing to pay than those using public facilities (p value = 0.000).
This means that, buying health services through direct payment (out of pocket) clearly affects
those having no health insurance and therefore were more likely willing to pay. One
unpredictable finding was the means of transportation variable to attend healthcare facility.
Respondents who use taxi as a means of transportation were more likely willing to pay than
those who use other means (p value = 0.040; CI: .041 - 1.735).
On the other hand, age, gender, chronic use of medication, and presence of chronic disease were
found to be non-significant with the maximum WTP. Similarly, neither marital status nor
existence of dependents were found to be statistically significant with maximum WTP.
Universal health coverage is a national target and the health system in the country struggles to
build an efficient and an equitable health care financing system for the entire population.
Informal sector workers are more vulnerable to out of pocket payment because they have no
social insurance. The only insurance available for them is the private insurance which is
unaffordable or they should pay fees for services which might lead to catastrophic expenditure
and push them to a further poverty. SHI in Sudan is a promising scheme for the informal workers
but has no evidence-based approach to address their preferences and to improve and sustain their
enrolment level. WTP for SHI among informal sector varies across countries. Several studies
came out with comparable results.
Based on the bidding game format used to illicit WTP of the informal sector workers, the normal
flat-rate stated by social health insurance (40 SDG) was the amount used to kick off the bidding
to determine WTP. From all surveyed communities, more than one fifth of the respondents were
willing to pay the starting bid to join the SHI. It seems difficult for the insurance to enroll more
people from the informal sector, as premiums increased there would be more people out of the
coverage. In Ghana, a WTP study of informal sector workers showed that 64% would sign up for
health insurance for a reasonable premium, compared to costs (Asenso-Okyere et al., 1997).
Our study suggested that socioeconomic factors including income and occupation were among
the main drivers of respondents’ WTP. WTP increased as income increased whereas regular
income from specific job was a strong motivator associated with high WTP compared to those
who did not have a regular income. This similar to findings of studies conducted in Taiwan and
India where people with higher income were more likely to pay than those with lower income
(Adams et al., 2015; Dror et al., 2007)
Risk transfer as a mechanism to reduce Social Vulnerability
International Strategy for Disaster Reduction (ISDR) defines the vulnerability as “the conditions
determined by physical, social, economic and environmental factors or processes, which increase
the susceptibility of a community to the impact of hazards” or also defined as a status, due to
human activities, which describes the impact of hazard on a society and the degree of social self-
protection (ISDR, 2004). Social vulnerability is influenced by various factors and processes
include those of physical, social, economic, and environmental nature. Such factors increase the
exposure of the community to the risk (s) of certain hazard (s). For instance: poverty, occupation
(employment), income, education level, human settlements, family structure, medical services,
people with special needs, caste, ethnicity, exclusion, marginalization, and inequities in
community. All these factors affect the social vulnerability (Dwyer, 2004; Singh et al., 2014;
Cutter et al. 2003). Health insurance is a social protection mechanism (risk transfer) that seeks to
protect the people against catastrophic payment at time of illness. This means that social
protection is considered as a component of vulnerability (Cannon, 2000) which typically linked
to a subgroup of population like informal sector workers who lack access to affordable health
care services provided through SHI, hence exposed to low level of resilience to health risks.
Therefore, in health care arena, SHI contributes to minimize certain aspects of social
vulnerability, improves access of vulnerable people, and promotes equity among entire
population of a country.
In light of the current research findings, social vulnerability of informal sector can be discussed
along with the three main components of vulnerability (predisposing, enabling, and need
components) that related to the behavioral model of health service use (Andersen, 1995;
Grabovschi et al., 2013). In terms of predisposing factors, the respondents have
sociodemographic characteristics which are linked to maximum WTP. Low educational level and
residence in rural areas were associated with low willingness to pay. Enabling components are
common among the respondents where they all lack participation in SHI. Further, poverty and
low-income levels (Pollack & Kronebusch, 2004) (no or one source of income) were associated
with people less likely willing to pay. Additionally, respondents demonstrated that they lack for a
regular source of health care. Respondents were approaching different types of health care
facilities to receive the services where those who use public health facilities were less likely
willing to pay than those who use private facilities. The need component is apparently related to
some respondents who have chronic diseases and require to be on regular medications. On the
other hand, respondents demonstrated different types and levels of adaptive capacities to reduce
their vulnerabilities. While some of them rely on traditional healers, others travel long distances
to attend cheap health services. Moreover, significant number of respondents rely on various
income sources to cope with escalated costs of livings and health care services. Not to mention
the fact that, donations and support from relatives and others were additional sources of income
disclosed by some respondents. The most important mechanism that the informal sector workers
were following is the participation in SHI on a selective basis where they opt-out when they feel
healthy. It’s considered a strong coping mechanism for the sector but it hinders achieving the
overall goal of universal coverage and disturbs the health insurance administration. In order to
ensure active participation of informal sector and promote equal access of the entire population,
it’s necessary to work on existing social vulnerability and health care disparities (Grabovschi et
al., 2013).

Conclusion
Health care financing is an essential component to achieve universal coverage. The SHI in Sudan
uses the tax funding to complement premiums of formal sector workers. Although some of the
informal sector workers having good income, the government system does not properly tax them.
Therefore, SHI should seek other alternative mechanisms to finance the scheme and give
incentives to the informal workers to attract them. Drawing on the study findings, 25% reduction
in monthly premium will ensure signing up of a good number of informal sector workers to SHI
and hence, substantial amount of fund will be added to the general finance of the scheme.
Therefore, informal sector is considered as a valuable financing source. The government should
build on alternative mechanisms to enroll such population.
One option could be the provision of subsidies through the national charity fund (Zakat
Chamber) particularly for people of lower socioeconomic status (Adams et al., 2015). The study
findings revealed that, 31% of the informal sector workers were in the poor category of the
wealth index which means that they require either subsidy or complete support. The second
option might be the adoption of a mix-model by establishing community-based health insurance
designed for informal sector and linked to SHI (co-share) to allow for more community
engagement and management. This option would be optimal solution for better off population
where it can be grounded on the fact that about half of the informal sector workers were in the
medium quintile of wealth index. On the other hand, urban population expressed high WTP
which indicates that, awareness campaigns about the health insurance benefit package and scale
of premiums will eventually improve their enrolment profile.
In this study, the contingent valuation method used to elicit WTP of the informal sector produced
objective findings that have policy implications. A reasonable premium policy can be decided to
sustain the informal sector participation in the scheme to achieve universal coverage while
maintaining costs of the services.
Furthermore, many social vulnerability aspects have been cited for the informal sector. The study
findings suggest that, health service mapping for the health insurance is very vital to improve the
service coverage around the deprived area particularly rural areas of Khartoum state to attract
more people based on the availability of services. The findings also suggested that, previous
medical spending, presence of chronic disease (s) and using chronic medications were not major
determinants for WTP of informal sector. This was quite different from other study findings
conducted in other developing countries (Bärnighausen et al., 2007).
Overall, socioeconomic factors, place of residence, and type of nearest health facility among
others were factors associated with maximum WTP. Nevertheless, additional qualitative studies
are highly recommended to avail information on consumer’s preferences and enrolment
behavior. Examining social vulnerability of informal sector workers will give profound
understanding and insight on the enrolment behavior as well as the efficiency of risk sharing and
risk transfer mechanisms that shape the fundamentals of the social health insurance.

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