The Challenges of Establishing Universal Health Coverage in Enugu State, South East Nigeria

This research was supported by UNN TETFUND Committee through TETFUND Institution Based Research Fund. Abstract Background: Financial risk protection for healthcare is deficient in Enugu state, Southeast Nigeria and the worst affected are the rural dwellers and the poorest, thus creating both socioeconomic and geographic inequity in access and use of services. The study aimed at eliciting the level of awareness and use of pre-payment mechanisms, and more importantly, determining the economic and political factors that facilitate or constrain achievement of Universal Health Coverage in Enugu state, Southeast Nigeria. Methods: Study was conducted in two purposively chosen urban and rural local government areas(LGA) of Enugu state with mixed method study design. Cross-sectional household questionnaire survey was conducted on 802 sample size from the two LGAs and 12 key informants participated in In-depth interviews (IDIs). The quantitative data was analysed with STATA using descriptive statistics while the qualitative IDI data was organized into nodes and sub-nodes using Nvivo: political and economic factors, corruption, communication/Awareness, capacity development / Infrastructure, policy development, leadership and referral system. Later, findings were thematically analysed. Results: The survey results showed that 84% of the study sample have secondary school education and 83% are engaged in employment or petty business. About 56% are aware of prepayment mechanism for healthcare bills but only 10% of them have used prepayment mechanisms. Out of pocket payment (85%) is the main source of payment at health facilities. Major political constraining factors to UHC revealed by the IDI include lack of political will backed with financial commitment from the political leaders, lack of legislative framework for UHC, lack of trust on the political leaders/government by the citizenry and inactive civil society organizations. Also, the poor fiscal space for health and the poverty level in the populace are big threats to sustainable UHC in Enugu state. Other economic challenges include corruption, poor health capacity development and poorly paid healthcare workers leading to poor quality of health care delivery. There is need for comprehensive health system development in the state to accommodate UHC. Conclusions: Establishment of sustainable UHC in Enugu state faces considerable political and economic challenges. There is need for increased government budgetary allocation for UHC to ensure coverage for the poor and vulnerable members. The lack of legislative framework for UHC could be resolved by legislative arm of the government. The government should invest in health system development to improve the quality of health care services to compliment the FRP component of UHC. Keywords: Universal Health Coverage, Health Insurance, Financial Risk Protection DOI: 10.7176/DCS/9-4-07 Publication date: April 30th 201

Improving equity in malaria treatment: Relationship of socio-economic status with health seeking as well as with perceptions of ease of using the services of different providers for the treatment of malaria in Nigeria

<p>Abstract</p> <p>Background</p> <p>Equitable improvement of treatment-seeking for malaria will depend partly on how different socio-economic groups perceive the ease of accessing and utilizing malaria treatment services from different healthcare providers. Hence, it was important to investigate the link between socioeconomic status (SES) with differences in perceptions of ease of accessing and receiving treatment as well as with actual health seeking for treatment of malaria from different providers.</p> <p>Methods</p> <p>Structured questionnaires were used to collect data from 1,351 health providers in four malaria-endemic communities in Enugu state, southeast Nigeria. Data was collected on the peoples' perceptions of ease of accessibility and utilization of different providers of malaria treatment using a pre-tested questionnaire. A SES index was used to examine inequities in perceptions and health seeking.</p> <p>Results</p> <p>Patent medicine dealers (vendors) were the most perceived easily accessible providers, followed by private hospitals/clinics in two communities with full complement of healthcare providers: public hospital in the community with such a health provider and traditional healers in a community that is devoid of public healthcare facilities. There were inequities in perception of accessibility and use of different providers. There were also inequity in treatment-seeking for malaria and the poor spend proportionally more to treat the disease.</p> <p>Conclusion</p> <p>Inequities exist in how different SES groups perceive the levels of ease of accessibility and utilization of different providers for malaria treatment. The differentials in perceptions of ease of access and use as well as health seeking for different malaria treatment providers among SES groups could be decreased by reducing barriers such as the cost of treatment by making health services accessible, available and at reduced cost for all groups.</p

Investigating determinants of out-of-pocket spending and strategies for coping with payments for healthcare in southeast Nigeria

<p>Abstract</p> <p>Background</p> <p>Out-of-pocket spending (OOPS) is the major payment strategy for healthcare in Nigeria. Hence, the paper assessed the determinants socio-economic status (SES) of OOPS and strategies for coping with payments for healthcare in urban, semi-urban and rural areas of southeast Nigeria. This paper provides information that would be required to improve financial accessibility and equity in financing within the public health care system.</p> <p>Methods</p> <p>The study areas were three rural and three urban areas from Ebonyi and Enugu states in South-east Nigeria. Cross-sectional survey using interviewer-administered questionnaires to randomly selected householders was the study tool. A socio-economic status (SES) index that was developed using principal components analysis was used to examine levels of inequity in OOPS and regression analysis was used to examine the determinants of use of OOPS.</p> <p>Results</p> <p>All the SES groups equally sought healthcare when they needed to. However, the poorest households were most likely to use low level and informal providers such as traditional healers, whilst the least poor households were more likely to use the services of higher level and formal providers such as health centres and hospitals. The better-off SES more than worse-off SES groups used OOPS to pay for healthcare. The use of own money was the commonest payment-coping mechanism in the three communities. The sales of movable household assets or land were not commonly used as payment-coping mechanisms. Decreasing SES was associated with increased sale of household assets to cope with payment for healthcare in one of the communities. Fee exemptions and subsidies were almost non-existent as coping mechanisms in this study</p> <p>Conclusions</p> <p>There is the need to reduce OOPS and channel and improve equity in healthcare financing by designing and implementing payment strategies that will assure financial risk protection of the poor such pre-payment mechanisms with government paying for the poor.</p

Cost-effectiveness analysis of rapid diagnostic test, microscopy and syndromic approach in the diagnosis of malaria in Nigeria: implications for scaling-up deployment of ACT

BACKGROUND: The diagnosis and treatment of malaria is often based on syndromic presentation (presumptive treatment) and microscopic examination of blood films. Treatment based on syndromic approach has been found to be costly, and contributes to the development of drug resistance, while microscopic diagnosis of malaria is time-consuming and labour-intensive. Also, there is lack of trained microscopists and reliable equipment especially in rural areas of Nigeria. However, although rapid diagnostic tests (RDTs) have improved the ease of appropriate diagnosis of malaria diagnosis, the cost-effectiveness of RDTs in case management of malaria has not been evaluated in Nigeria. The study hence compares the cost-effectiveness of RDT versus syndromic diagnosis and microscopy. METHODS: A total of 638 patients with fever, clinically diagnosed as malaria (presumptive malaria) by health workers, were selected for examination with both RDT and microscopy. Patients positive on RDT received artemisinin-based combination therapy (ACT) and febrile patients negative on RDT received an antibiotic treatment. Using a decision tree model for a hypothetical cohort of 100,000 patients, the diagnostic alternatives considered were presumptive treatment (base strategy), RDT and microscopy. Costs were based on a consumer and provider perspective while the outcome measure was deaths averted. Information on costs and malaria epidemiology were locally generated, and along with available data on effectiveness of diagnostic tests, adherence level to drugs for treatment, and drug efficacy levels, cost-effectiveness estimates were computed using TreeAge programme. Results were reported based on costs and effects per strategy, and incremental cost-effectiveness ratios. RESULTS: The cost-effectiveness analysis at 43.1% prevalence level showed an incremental cost effectiveness ratio (ICER) of 221 per deaths averted between RDT and presumptive treatment, while microscopy is dominated at that level. There was also a lesser cost of RDT ($0.34 million) compared to presumptive treatment ($0.37 million) and microscopy ($0.39 million), with effectiveness values of 99,862, 99,735 and 99,851 for RDT, presumptive treatment and microscopy, respectively. Cost-effectiveness was affected by malaria prevalence level, ACT adherence level, cost of ACT, proportion of non-malaria febrile illness cases that were bacterial, and microscopy and RDT sensitivity. CONCLUSION: RDT is cost-effective when compared to other diagnostic strategies for malaria treatment at malaria prevalence of 43.1% and, therefore, a very good strategy for diagnosis of malaria in Nigeria. There is opportunity for cost savings if rapid diagnostic tests are introduced in health facilities in Nigeria for case management of malaria

Is community-based health insurance an equitable strategy for paying for healthcare? Experiences from southeast Nigeria.

OBJECTIVES: To determine how equitable enrolment and utilization of community-based health insurance is in two communities with varying levels of success in implementing the scheme. METHODS: The study was undertaken in two communities in Anambra state, southeast Nigeria. Data was collected using a questionnaire that was administered to 971 respondents in two communities selected by simple random sampling. Data analysis examined socio-economic status (SES) differences in enrolment levels, utilization, willingness to renew registration and payments. RESULTS: Enrolment level was 15.5% in the non-successful community and 48.4% in the successful community (p<0.0001). However, there was no inequity in enrolment, willingness to renew registration and utilization of services. Equal amounts of money were paid as registration fee and premium by all SES quartiles. There were no exemptions and no subsidies. CONCLUSION: Enrolment was generally low and contributions were retrogressive. The average premiums were also small. However, there was equitable enrolment and utilization of services. Efforts need to be made to increase the number of enrolees, so as to increase the pool of funds and risks. Payments by enrolees especially in poor and rural communities should be supplemented by subsidies from government and donors in order to ensure equitable financial risk protection

Improving quality of malaria treatment services: assessing inequities in consumers' perceptions and providers' behaviour in Nigeria

<p>Abstract</p> <p>Background</p> <p>Information about quality of malaria treatment services of different healthcare providers is needed to know how to improve the treatment of malaria since inappropriate service provision leads to increased burden of malaria. Hence, the study determined the technical and perceived quality of malaria treatment services of different types of providers in three urban and three rural areas in southeast Nigeria.</p> <p>Methods</p> <p>Questionnaire was used to interview randomly selected healthcare providers about the technical quality of their malaria treatment services. Exit polls were used to obtain information about perceived quality from consumers. A socio-economic status (SES) index and comparison of data between urban and rural areas was used to examine socio-economic status and geographic differences in quality of services.</p> <p>Results</p> <p>The lowest technical quality of services was found from patent medicine dealers. Conversely, public and private hospitals as well as primary healthcare centres had the highest quality of services. Householders were least satisfied with quality of services of patent medicine dealers and pharmacy shops and were mostly satisfied with services rendered by public and private hospitals. The urbanites were more satisfied with the overall quality of services than the rural dwellers.</p> <p>Conclusion</p> <p>These findings provide areas for interventions to equitably improve the quality of malaria treatment services, especially for patent medicine dealers and pharmacy shops, that are two of the most common providers of malaria treatment especially with the current change of first line drugs from the relatively inexpensive drugs to the expensive artemisinin-based combination therapy, so as to decrease inappropriate drug prescribing, use, costs and resistance to artemisinin-based combination therapy.</p

Is community-based health insurance an equitable strategy for paying for healthcare? Experiences from southeast Nigeria

Objectives To determine how equitable enrolment and utilization of community-based health insurance is in two communities with varying levels of success in implementing the scheme.Methods The study was undertaken in two communities in Anambra state, southeast Nigeria. Data was collected using a questionnaire that was administered to 971 respondents in two communities selected by simple random sampling. Data analysis examined socio-economic status (SES) differences in enrolment levels, utilization, willingness to renew registration and payments.Results Enrolment level was 15.5% in the non-successful community and 48.4% in the successful community (p Community-based health insurance (CBHI) Anambra state Nigeria Equity Financial risk protection

Assessment Of Health Seeking Behaviour And Healthcare Payment Options In Nigeria

Availability of resources, location of residence, and other health related factors affects the health seeking behaviour of people in Nigeria especially people in poor settlements. Many of the citizens pay for their healthcare needs through the regressive out-of-pocket payment method thus this could be a hindrance to seeking better healthcare. This study assessed the health seeking behaviour and payment options of slum dwellers using a one month recall period. Data was collected using a well-structured interviewer-administered questionnaire. The quantitative statistical tools used in the study analysis were tabulations, frequencies and testing of means. The findings showed that about 32.8% of the heads of households and 25% of other household members were sick one month prior to the interview. The major illnesses was presumptive malaria (54.9%) and (55.1%) for heads of household and other household members respectively. Majority of the head of households and other household members first sought for treatment from patent medicine vendors. The major payment option available for slum dwellers to pay for their health needs was through the out-of-pocket and it was used by 62.1% of heads of households and 73.2% of other household members. Only about 3% of the household heads and about 3.9% of other household members had any form of health insurance. The policy implication is the poor health seeking patter where majority seeks care at patent medicine vendors may be improved with a good financial risk protection mechanism such as health insurance, which will improve access