Population Characteristics and Their Implications on the Benefit Basket of National Social Health Insurance Scheme in Sierra Leone: A Prospective View

Background. /e government of Sierra Leone introduced social health insurance (SHI) scheme to provide universal health coverage to people. /is study was carried out to assess the population characteristics and their implications on the benefit basket of the proposed national health insurance scheme.Methods. A cross-sectional study design was employed in six selected districts in Sierra Leone. Quantitative data were collected for this study through the use of semistructured questionnaires with a sample of 1,185 respondents. Data were analysed using descriptive and inferential statistics. Statistical analysis was run at 5% significant level using Stata 14.0 software. Results. /e study found that most (83.54%) of the respondents affirmed that children below 18 years should be excluded from premium payments and as high as 71.65% also stated that pregnant women should be excluded as well. /e majority, 63.69%, of the respondents want lactating mothers to be excluded from premium payments. Also, 79.87% of respondents wanted mentally challenged persons not to pay premium, while a significant proportion (84.26%) of respondents further affirmed that the aged (above 70 yrs) should also be excluded from premium payment. Most household heads (89.71%) preferred the accreditation of public health facilities. Regarding the level at which healthcare services should be covered by the scheme, 61.45% preferred the primary care services, 89%mentioned secondary care services, and 98.93% affirmed the provision of tertiary care under the scheme. As for the type of care that should be covered by the scheme, 98.66% and 99.73% affirmed outpatient and inpatient care, respectively. Conclusion. From the findings on population characteristics and their implications on the benefit basket for the proposed nation social health in Sierra Leone, most of the household heads want exemptions from paying premium for a section of the population. /is provides a clear insight for policy makers into the formulation of the benefit basket.


Background
A number of low and middle income countries (LMICs) have realised the difficulties associated with how to sustain sufficient financing for healthcare, most especially for the poor [1][2][3]. In view of this, international policy makers and other stakeholders have been recommending a variety of suitable measures, including, but not limited to, various kinds of health insurance schemes, one of which is social health insurance (SHI) [4,5].
is can help to move away from out-of-pocket payments for healthcare at the time of use with prepayment health insurance towards mitigating the financial hardship associated with paying for health services [6].
e World Health Organisation (WHO) passed a resolution in 2005 that social health insurance should be supported as one of the strategies to be used to mobilise more resources for healthcare service delivery, for risk pooling, increasing access to healthcare for people who are poor, and for delivering quality healthcare especially in low income countries [7]. Health insurance is considered a medium to share the financial risk associated with different kinds of individuals' healthcare costs by pooling the costs over time through the use of prepayment [8,9]. Whenever general healthcare coverage is to be funded through insurance, the risk pool needs to portray certain characteristics; (i) contributions to the risk pool should be involuntary so as to thwart the rich and healthy from opting out; (ii) the risk pool should have great numbers of people, as pools with few numbers cannot broaden the risk satisfactorily and are too small to handle large healthcare costs; and (iii) where the majority of the members are poor, pooled funds will generally be subsidised from government revenue [6,10].
It is important at this point to determine the health benefit basket.
us, the policy should clarify "services, procedures, activities, and goods" that are publicly covered in a specific country. e benefit basket entails three main indicators: breadth, depth, and height. e breadth signifies the populations that are covered, whereas the depth indicates the resources provided, and the height explains the scope of the costs of the services covered. All services, procedures, activities, and equipment that are not covered (i.e., entailing a 100% copayment) are considered not to be part of the benefit basket or package. Worldwide, the health benefit catalogue is broadly divided into hospital inpatient care, pharmaceuticals, primary care (including outpatient, general, and specialised care), and others (preventive services, allied professional care). Among these broad areas, different methods are used to state the specific catalogues of the package [8,11] Sierra Leone is estimated to have the world's highest maternal mortality ratio. Anaemia is a serious public health problem among pregnant women (70%) [12]. is could be explained partly by poor access to healthcare services at the time of giving birth and also that the majority of Sierra Leone's population pay user fees to access healthcare [13]. To address financial inaccessibility, the Free Healthcare Initiative was introduced in 2010 to abolish user fees for all pregnant and lactating women and under-five children [14]. Furthermore, Ministry of Health and Sanitation started the implementation of the newly developed National Health Sector Strategic Plan 2017-2021. Again, government launched the Sierra Leone Social Health Insurance (SLeSHI) in 2018 to improve financial accessibility to healthcare [15].
is study was carried out to assess the characteristics of the population and their implications for the benefit basket of the proposed national health insurance scheme in the country.

Study Design.
is study is a cross-sectional study by design and analytical by type. It covered the household population in six selected districts in Sierra Leone: Kono (505,491), Bo (574,026), Koinadugu (408,687), Bombali (605,741), Western Area Urban (1,050,711), and Western Area Rural (443,068). A total household population of 3,587,724 was used as a target population. e sample size was estimated from the study population using Sample Size Calculator version 2.0.2 by Relief Applications (https://play. google.com 〉 store 〉 apps 〉 details 〉 id � calculate.sample.size). In this study we used 95% confidence level and a precision rate of 0.03 to arrive at a sample size of 1,185 households from the total household population (3,587,724).

Sampling Procedure.
A simple random technique was used to select the respondents. is was to ensure that every individual had an equal chance of being selected. A systematic sampling was used to select houses. Every third house was selected, and household heads who fell within the target group were identified and interviewed. Where there was more than one eligible respondent in a house, only one of them was randomly selected, through balloting, to participate in the study. On the other hand, where there was no eligible respondent, interviewers moved to the next house.
is process continued until the required number was reached.

Data
Analysis. Data for this study was obtained from a household head through the use of semistructured questionnaire after it was pretested. We used Stata version 14.0 to analyse the data obtained from the study. Both inferential and descriptive analysis were done at 5% significance level.

Sociodemographic Characteristics of Respondents.
e sociodemographic characteristics of respondents which involve district of household, head, location, age, gender, marital status, religion, occupation, monthly income, and educational qualification are presented in Table 1. From the findings, the majority (29.28%) of household heads were from Western Area Urban district. In terms of location of household heads in the district, more than half (69.28%) were from urban areas. e study revealed that the majority (43.63%) of household heads are within the age bracket of 30-39 years and had attained tertiary education (39.92%). Most (67.76) of the respondents were males. Vast majority of the respondents (72.24%) were married. A little over half (52.66%) of the respondents were Christians. Regarding occupation, a little over two-thirds (62.95%) were informal workers. As for household heads' monthly income (mean-� Le 1,069,945; SD � Le 1,307,152), about 4 in 10 (37.47%) were earning less than Le 500,000.

Population Characteristics and
eir Implications on Benefit Basket. In this section, the population characteristics (qualities and characterization of the people based on demography, health status, socioeconomic factors, willingness, and ability to pay for a health-related programme) were assessed in order to be able to formulate appropriate benefit basket for the proposed national health insurance scheme in Sierra Leone, Table 2.
Regarding sources of healthcare, slightly above half of respondents (51.05%) go to a chemist shop as a first step when a member is sick. A vast majority (94.09%) of the respondents used public health facilities. Out-of-pocket payments accounted for the largest (92.57%) source of funding health. e data pointed out insufficient funds as the biggest challenge (70.89%). e majority (76.29%) were not aware of the proposed SLeSHI. A vast majority (94%) of the respondents were willing to join and pay the premium. e mean insurance premium was Le 14,089.45 (SD � Le 18,690.41), and less than half (44.99%) were willing to contribute Le 10,000-19,000. e majority (51.97%) who were willing to make monthly contributions belonged to the formal sector. With respect to the preferred mode of premium payment by household heads, 79.52% preferred monthly payment whereas less than 1% (0.09%) preferred paying the premium once in a lifetime. About two-thirds (60.91%) of the respondents were willing to accept any form of cost sharing, while the rest (39.09%) were not. Among those that were willing to accept any form of cost sharing, a little over half (54.33%) preferred coinsurance. Respondents were further asked if they had confidence in the government for the sustainability of the insurance scheme. Less than a fifth, 13.77%, of respondents indicated that they were not confident.

Relationship between Sociodemographic Characteristics and Willingness to Join the Proposed Health Insurance.
Chi-square test was run to assess the relationship between sociodemographic characteristics and willingness to join the proposed health insurance, Table 3. ere was a statistically significant relationship between the willingness to join the proposed SLeSHI and the district in which the individual stays, marital status, religion, occupation, monthly income, educational qualification, and awareness of SLeSHI implementation.

Preferred Choices for Benefit Basket.
Benefit basket includes all services, procedures, activities, and goods covered by public funding in a given country. Any of these that are not covered are not considered part of the benefit basket. is study assumed that to formulate an adequate benefit basket and to have an acceptable level of participation by clients, the characteristics of the population of a country need to be assessed for their preferred choices about the content and scope of the benefit basket for the implementation of SLeSHI (Table 4).
From Table 4, most (83.54%) respondents affirmed that children below 18 years should be excluded from premium payments, and as high as 71.65% also stated that pregnant women should be excluded as well. e majority, 63.69%, of the respondents were of the view that lactating mothers should be excluded from premium payments. In addition, 79.87% of respondents stated that mentally challenged persons should not pay premium while a significant proportion (84.26%) of respondents further affirmed that the aged (above 70 yrs) should also be excluded from premium payment.
Most household heads (89.71%) preferred the accreditation of public health facilities. Regarding the level at which healthcare services should be covered by the scheme, 61.45% preferred the primary care services, 89% mentioned secondary care services, and 98.93% affirmed the provision of tertiary care under the scheme. In respect of the type of care that should be covered by the scheme, 98.66% and 99.73% affirmed outpatient and inpatient care, respectively.

Discussion
e findings from the study showed that the majority of the household heads go to the chemist shop as a first step taken whenever a member is sick. is may be attributed to the closeness as well as the informal relations households have with chemical shop operators. Moreover, the attitude of healthcare providers, affordability, and proximity to healthcare services at the facility level may be contributing to this decision of household heads [16]. In the case of those who seek care at the hospital, they prefer public health facilities. e reason may be that public facilities are more accessible compared to other types of facilities. From the study, out-of-pocket payment accounted for the highest source of funding for health-related expenditure which is in line with an earlier study [10], and the implication is that it may lead to a huge financial burden on or catastrophic spending for the people.
In this study, we found that the majority of respondents were not aware of the implementation of the proposed SLeSHI. is could be explained by the fact that the government has not developed much awareness about the scheme. is is in contrast to the findings of [17], who found that more than half of the public servants in Juba City are aware of NHIF. On the other hand, in Nigeria, [18] found that less than half of the participants were aware of community-based health insurance schemes (CBHIS), which corroborates the findings of this study.
Furthermore, it was found that majority of household heads were willing to join the scheme and pay the premium with a few disagreeing. e reason for willingness to join was that they would benefit from the scheme as the government would take care of their high health-related expenditure and help their family members to access healthcare by reducing their direct out-of-pocket payment; they also believed that it would be helpful to them in times of emergency when Advances in Public Health money may not be readily available in seeking healthcare due to the uncertainty of disease occurrence. ose who said they were not willing to join the scheme perceived that the premium contributions might be high as they have other family responsibilities to address. Some respondents also stated a lack of trust and confidence in the government for the sustainability of the program and believed that corruption could collapse the scheme. A significant number of household heads were willing to contribute a mean of Le 14,089.45, 95% CI (12992.67-15186.22), as premium. is may be attributed to the fact that the majority of the household heads were educated and therefore knew the importance of subscribing to the health insurance schemes. is study further reveals that more than half of the formal workers are willing to contribute to the proposed scheme. is may be explained by the fact that most of them are educated and therefore know the benefits associated with subscribing to health insurance. ese findings are in line with earlier studies which identified education, income, and age as factors that influence people's willingness to subscribe and pay for health insurance. A study conducted by [17] in South Sudan among public servants in Juba City reveals that willingness to pay is primarily affected by education. Moreover, [10] found that, among civil servants in the city of Mekelle, the northern part of Ethiopia, willingness to pay has been correlated significantly with age, educational level, and household income.
However, the amount of money respondents said they would like to pay as premium is inconsistent with the proposed 4% premium contribution from formal workers as per the proposed national health insurance scheme in Uganda and Arusha (2014) as cited by [17]. is may imply that the residents in Sierra Leone are not willing to pay any amount that is beyond the said mean contributions, especially the informal workers. Moreover, it implies that the funds that will be available for the scheme when established will be significantly low, except that there are other sources of funding which could be from the central government, corporate bodies, and external sources. With this low level of average amount that clients are willing to pay vis-a-vis the high prevalence of the disease, a comprehensive analysis is warranted for an appropriate and adequate content, scope, and depth of the benefit basket. Using only the willingness to pay may have a dire consequence on the quality of service delivery and sustainability of the scheme.
According to the WHO Universal Health Coverage cube, the formulation of benefit basket depends on three dimensions of coverage: the breadth which refers to the population coverage, the depth (service coverage), and height (cost coverage) In this study, individuals from six selected districts in Sierra Leone, including both formal and informal workers, were examined on their preferences for the benefit basket for the proposed national social health insurance scheme. is study assumes that the preference of the population provides a significant policy input in formulating the benefit basket for the SLeSHI and supports the participation of the populace for higher enrolment to sustain the scheme.
A clear picture of the preference of individuals as to the benefit basket is necessary to estimate the insurance uptake rate and the implementation of a SHI scheme [19]. e study explored who should be in the exemption bracket. A majority of respondents are of the view that children below the age of 18 years, pregnant women, lactating mothers, mentally challenged individuals, and the aged (above 70 years) should be exempted. is exemption list of national health insurance does not conform to the best practice in many health insurance countries like Burkina Faso, Tanzania, Ghana, and Rwanda as majority of the insured are below 18 years and above 70 years. In Ghana, for instance, a study [20] found that about 56 percent of the insured were below 18 years and above 70 years. is may mean that a lot of financial burden may be on the scheme which can affect the quality of care and render the NHIS insolvent.
Moreover, a majority of respondents prefer that the public health facilities should be more accredited compared to private and mission facilities. is is so because public health facilities in Sierra Leone are more than private and mission ones and the cost of care is cheaper for the public than the latter. e results could be due to the fact that this study covered more rural than urban areas which are served by public health facilities.
For service coverage, the study shows that there is a preference for the coverage of all three levels of care (primary, secondary, and tertiary), with tertiary care accounting for the highest preference, followed by secondary and primary care, respectively. ey also prefer coverage of both outpatient and inpatient care. e above preference for coverage of services means that the government of Sierra Leone will bear the major burden of the scheme on the grounds that the people are willing to pay less monthly premium. Covering the preferred services may require a substantial fund for the scheme. It means, for the formulation of an attractive benefit basket, that the scheme may require extra financial support outside the household to protect the populace from a catastrophic expenditure. is finding is not surprising as it is in line with a study conducted in Nigeria on the preference for benefit packages for community-based health insurance [21], in which it was also found that people preferred a benefit basket that covers everything including inpatient and outpatient services. It is also similar to the findings in a previous study by Dong et al. (2004), which revealed a strong preference for the covering of high-cost healthcare services.

Strengths and Limitations.
e study was one of the few studies done on the proposed SLeSHI, characterising the population, covering more rural areas, and focusing on the benefit basket for the proposed social health insurance scheme. However, like any cross-sectional study design, it is possible that the results may have been affected by social desirability, sample variability, and recall bias which could have under-or overestimated the income and amount of money the respondents said they are willing to pay as premium. Besides, it did not cover disease preferences of the people that need to be covered. Nevertheless, the study upheld the measures to ensure validity and reliability by employing random sampling, pretesting tools, making statistical adjustments such as design effects and nonresponse rates, and subjecting the study protocols to Institutional Review of Board, Office of the Sierra Leone Ethics and Scientific Review Committee, which are consistent with best scientific practice. We strongly believe that these measures reduced the errors to the barest level and would not have any dire effect on the policy utility of the findings.

Conclusions
Majority of the household heads want children below 18 years, pregnant and lactating mothers, and the aged, 70 yrs and above, as well as the mentally retarded to be excluded from premium payment. is will go a long way to reduce maternal mortality rate as well as increasing the general population access to healthcare.

Abbreviations
USD: United States dollar LMIC: Low-and middle-income countries SHI: Social health insurance WHO: World Health Organisation UHC: Universal health coverage.

Data Availability
Data for this study will be made available upon request.

Ethical Approval
Ethical approval was sought from the Ethical Review Board of Sierra Leone.

Consent
A written consent form was issued to respondents to seek their consent to participate in the study. ey were assured that their contribution to the study would be confidential and the data provided can only be used for the study. e respondents were also informed that no form of financial incentive will be given to them for being part of the study and that their choice of not being part of the study cannot stop them from getting any benefit that may come as a result of the study.

Conflicts of Interest
e authors declare no conflicts of interest.

Authors' Contributions
A. I. J. and P. A.-B. conceived and initiated the study. A. I. J. designed the study, provided training and guidance for data collection and analysis, and further prepared the original draft of the manuscript. P. A.-B. assisted with supervision, editing, and technical support in all areas of the study. A. B. and H. M. C. assisted with the data collection and provided monitoring to the entire team for data collection. e draft manuscript was critically reviewed by P.T. P. A.-B. and A. I. J. are the guarantors. All authors made significant contributions to the final work; read and approved the manuscript for submission; and gave their consent for the manuscript to be published.