Gender's effect on willingness-to-pay for community-based insurance in Burkina Faso
Introduction
‘Gender refers to women's and men's roles and responsibilities that are socially determined. Gender is related to how we are perceived and expected to think and act as women and men because of the way society is organised, not because of our biological differences’ [1]. In the social and economic aspects, women are usually located primary responsibility for household and domestic labour—for the care of children, the elderly and the sick. Conversely, men are much more closely identified with public world—with the activities of waged work and the rights and duties of citizenship [2]. Gender has been found to influence health, access to health care, quality of care, risks to get tropical infectious diseases, HIV/AIDS and other sexually transmitted diseases, violence and injuries [1]. Males are more exposed to malaria infection for occupational reasons [3]. At young ages, the prevalence of tuberculosis infection in boys and girls is similar, but a higher prevalence has been found in men of older ages [4]. More men than women are diagnosed with tuberculosis, however, women have longer delays in tuberculosis diagnosis [5], [6]. Women vulnerability to HIV/AIDS has been recognised as being due to lack of knowledge and access to information, economic dependence and in many cases, forced sex [1].
Willingness-to-pay (WTP) is used to estimate utility in monetary terms. Economic theory argues that the maximum amount of money an individual is willing to pay for a commodity is an indicator of the utility or satisfaction to her of that commodity. WTP is one of the economic techniques for eliciting consumer preference. Recently WTP studies have been carried out in the various fields of health, including disease treatment, disease management, new medical technology, outcome evaluation of health care and health program, and the common used methods were the bidding game, the payment card and the take-it-or-leave-it [7], [8].
Although there are many studies about gender and WTP in various areas of health and health care, there are no studies to combine gender and WTP together to identify the effect of gender on WTP in these areas. Even in the area of rural health insurance only two WTP studies have been carried out. In Ghana, a study used the bidding game method to interview five-member household heads and to assess the willingness of households (164 urban households and 142 rural households) in the informal sector to join and pay premiums for a proposed National Health Insurance scheme [9]. The study used sex as one independent variable in the multivariate analysis. But it did not describe the social and economic characteristics between sexes and did not analyse the WTP difference between sexes either. Thus the study could not provide information about the effect of gender. Another study was done in India. The heads of 1000 households in rural area were asked directly which type of health insurance scheme they preferred and how much they were willing to pay for the chosen scheme [10]. This study did not consider the effect of sex in the multivariate analysis, so the same as the former study, it could not provide information about effect of gender on WTP.
Compared to other studies, the present study merged gender and WTP, focused on gender's effect on WTP for community-based insurance (CBI). Each household member aged 20 and more was asked WTP for him/herself. This study was carried out in rural Burkina Faso and described the characteristics of gender and quantitatively analysed the effect of gender on WTP by the indicator of WTP difference between male and female.
Our hypothesis was that WTP was related to individual preferences (utility) under certain specifications (theory of utility maximisation). An individual stating WTP of a certain amount or not is based on expected utility. If the expected utility to be derived from participating in the scheme at the stated premium is greater than the amount of the premium, an individual will opt to pay. In this context, it was assumed WTP would be affected by age, years of schooling, occupation and marital status. It would also be affected by relationship to household head, location of residency, economic and health status, and distance to health facility. The aged was expected to be willing to pay less; household head, higher income, higher education, urban people and people with poor health could be expected to be willing to pay more for the health insurance premium. Longer distance to health facility can reduce WTP.
This paper based on a WTP study for CBI in Nouna, Burkina Faso, which was a part of a larger project on the control of tropical infectious diseases. Burkina Faso has an estimated population of approximately 10.7 millions [11]. This small West African country is divided into 11 administrative health regions, which comprise 53 health districts overall, each covering a population of 200 000–300 000 individuals. Each health district has at least one hospital with surgical facilities [12]. The districts themselves are again sub-divided into smaller areas of responsibility that are organised around either a hospital or a so-called Centre de Santé et de Promotion Sociale (CSPS), the first-line health care facility in the health system. The Nouna health district, located in the Northwest of Burkina Faso, has a population of roughly 230 thousand inhabitants who are served by one district hospital and 16 CSPS.
Section snippets
Sampling procedure and sample size
The household survey, which was conducted by the project of control of tropical infectious diseases, was based on a two-stage cluster sampling procedure, with each household having the same probability of being selected. In the first stage, clusters of households were selected and in the second stage, respondent households were selected in each cluster. Overall, 800 households were selected, 480 in the rural area and 320 in the town of Nouna [13]. We used this sample and merged WTP questions
Gender characteristics
Compared to male, female had significantly lower education, farmer occupation, income, expenditure, episodes of diseases and lower ratio of becoming household head, but higher marriage rate. There were no significant differences between sexes in the aspects of age, location of residency, religion, distance to health facility and the first bid (Table 1). All significant differences between men and women came from social factors; thus implying that gender would be responsible for the gap between
Discussion
It is clear that gender is a central factor in understanding the WTP difference between male and female because we found that women had less education, lower income and higher marriage rate which were the main factors to influence WTP in this study. Other factors can also influence WTP, such as age, location of residency, distance to health facility and the first bid, but we found that there were no significant differences between men and women in this study.
Traditional African societies, there
Conclusion
The gender characteristics in Burkina Faso are that female, compared to male, has less education, farmer occupation, lower income, expenditure, less episodes of diseases and lower ratio of becoming household head, but higher marriage rate. These characteristics influence the WTP for CBI between men and women. A decision-maker needs to take into account the gender difference in WTP in deciding the enrolment unit and in setting premium of CBI. Based on the results from this study, we suggest that
Acknowledgements
This paper is one of the results of ‘control of tropical infectious diseases’ project in Burkina Faso financially supported by Germany Research Foundation (Deutsche Forschunsgemeinschaft) (SFB 544). It is acknowledged that in the data collection we obtained valuable help from Sanou Aboubakary, Adjima Gbangou, Yazoumé Yé and Mamadou Sanon from Nouna Health Research Centre. We are also grateful to Vinod Diwan in IHCAR, Karolinska Institute for valuable comments and suggestions.
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