Effects of a temporary suspension of community-based health insurance in Kwara State, North-Central, Nigeria

Pan African Medical Journal, Volume 41, Year 2022

Interpretation

Introduction: a subsidized community health insurance programme in Kwara State, Nigeria was temporarily suspended in 2016 in anticipation of the roll-out of a state-wide health insurance scheme. This article reports the adverse consequences of the scheme´s suspension on enrollees´ healthcare utilization. Methods: a mixed-methods study was carried out in Kwara State, Nigeria, in 2018 using a semi-quantitative cross-sectional survey amongst 600 former Kwara community health insurance clients, and in-depth interviews with 24 clients and 29 participating public and private healthcare providers in the program. Both quantitative and qualitative data were analyzed and triangulated. Results: most of former enrollees (95.3%) kept utilizing programme facilities after the suspension, mainly because of the high quality of care. However, majority of the enrollees (95.8%) reverted to out-of-pocket payment while 67% reported constraints in payment for healthcare services after suspension of the program. In the absence of insurance, the most common coping mechanisms for healthcare payment were personal savings (63.3%), donations from friends and families (34.7%) and loans (11.8%). Being a male enrollee (odd ratio=1.61), living in a rural community (odd ratio =1.77), exclusive usage of Kwara Community Health Insurance Programme (KCHIP) prior to suspension (odd ratio=1.94) and suffering an acute illness (odd ratio=3.38) increased the odds of being financially constrained in accessing healthcare. Conclusion: after the suspension of the scheme, many enrollees and health facilities experienced financial constraints. These underscore the importance of sustainable health insurance schemes as a risk-pooling mechanism to sustain access to good quality health care and financial protection from catastrophic health expenditures. Study design and study population: in August 2018, about 2 years after the suspension of KCHIP (Figure 1), a mixed-method study was carried out among KCHIP former enrollees and healthcare providers in Kwara State, Nigeria. Using multi-stage random sampling, we recruited a total of 600 enrollees whose health insurance policy had expired at least 4 months before the end of December 2016. For the quantitative cross-sectional survey we obtain data on socio-demographics, healthcare utilization, enrolment status, health financial constraints and coping strategies since the suspension. Only adults (18 years and above) were included in the study, of whom a purposively selected 400 enrollees had accessed care in a KCHIP healthcare facility in the preceding 12 months. The remaining 200 participants were selected from those uninsured in the past 12 months. Of those 400 participants who have accessed healthcare, half (200) who had in addition to other health conditions been seeking chronic care, maternal care and care for acute conditions were included in the study. In-depth interviews (IDIs) were performed among 24 purposively selected former enrollees and among 29 health facilities´ managers of (19 public, 10 private) participating KCHIP facilities. The IDIs explored the effects of the programme suspension on both healthcare utilization by former enrollees and their coping mechanisms, and health facilities´ service provision. To be selected for the IDI, the participant must be above 18 years of age and must have utilized pertinent healthcare in the past 12 months. To obtain healthcare utilization pattern due to the programme suspension, health facilities´ clinical records were reviewed as part of the observation checklist tool developed for the qualitative data collection. Quantitative study: multi-stage sampling was used, selecting 5 Local Government Areas (LGAs): two from Kwara South, two from Kwara North and one from Kwara Central senatorial zones. Enrollees were selected randomly with the KCHIP enrollment database serving as sampling frame after allocating LGAs proportionate to constituent population sizes (total enrollment in the 5 LGAs in January 2016 was 73,438). An additional 30% was added from the sample frame for each LGA to cater for non-response and untraceable enrollees. The selected enrollees were traced in the community (with the help of community mobilizers) and interviewed by trained interviewers. The questionnaire captured data on respondents´ socio-economic characteristics, morbidity patterns, healthcare access and utilization in the preceding 12 months. Qualitative study: we conducted two rounds of IDIs among former enrollees and facilities´ managers. The enrollees´ interviews were conducted among 24 purposively selected adults across 9 selected LGAs cutting across the 3 zones of Kwara State. The selection of former enrollees into the IDIs was carried out in and around the health facilities using a pretested interview guide. The facility managers´ interviews were conducted in KCHIP facilities among the officers-in-charge (or the medical director). This comprised all 29 Enhanced Community Based Care (ECBC) health facilities (19 public, 10 private) spread across 9 LGAs; 13 health posts providing remote care services were excluded from the study because they were already linked to records of the 29 ECBCs. Data analysis:the quantitative data entry platform was designed using Open Data Kit® (ODK), while the data was entered using Kobo Toolbox® [14] and later exported to Statistical Package for Social Science (SPSS) version 22 for analysis. Simple logistic regression was used to explore the predictive factors of the financial constraints in the ability to pay for healthcare services after the programme suspension. The level of significance was set at a p-value of < 0.05 complemented with a 95% confidence interval (CI). Recorded qualitative interviews were transcribed and thematic analysis was carried out manually. Mixed results of the qualitative and quantitative data were triangulated and reported together to complement major contextual observations in this study. Ethics approval and consent to participate: written permissions were obtained from the ethics committee of the Kwara State Ministry of Health, Ilorin, Nigeria. Informed consent was obtained from the participants. Confidentiality of the participants´ and health facilities´ information were maintained.

AI Digest

Study Justification:

The study aimed to investigate the effects of the temporary suspension of the community-based health insurance program in Kwara State, Nigeria. The justification for the study was to understand the adverse consequences of the suspension on enrollees’ healthcare utilization. This information is crucial for policymakers and stakeholders to make informed decisions regarding the implementation and sustainability of health insurance schemes.

Highlights:

1. The majority of former enrollees (95.3%) continued to utilize healthcare facilities after the suspension due to the high quality of care.
2. However, after the suspension, 95.8% of enrollees reverted to out-of-pocket payment, leading to financial constraints in accessing healthcare services.
3. Common coping mechanisms for healthcare payment included personal savings, donations from friends and family, and loans.
4. Male enrollees, those living in rural communities, exclusive users of the Kwara Community Health Insurance Programme (KCHIP) prior to suspension, and those suffering from acute illnesses were more likely to face financial constraints in accessing healthcare.
5. The findings highlight the importance of sustainable health insurance schemes as a risk-pooling mechanism to ensure access to quality healthcare and protect individuals from catastrophic health expenditures.

Recommendations:

1. Reinstate and strengthen the community-based health insurance program in Kwara State to provide financial protection and improve access to healthcare services.
2. Develop strategies to address the financial constraints faced by enrollees, such as exploring options for subsidized premiums or expanding the coverage of the state-wide health insurance scheme.
3. Enhance public awareness and education about the benefits and importance of health insurance to encourage enrollment and participation.
4. Collaborate with key stakeholders, including government agencies, healthcare providers, and community leaders, to ensure the successful implementation and sustainability of health insurance schemes.

Key Role Players:

1. Kwara State Ministry of Health: Responsible for policy development, implementation, and oversight of health insurance programs.
2. Community Mobilizers: Assist in identifying and reaching out to former enrollees for data collection and program re-engagement.
3. Health Facilities’ Managers: Collaborate with policymakers to ensure the provision of quality healthcare services and support the implementation of health insurance programs.
4. Government Agencies: Provide financial support and regulatory frameworks for the implementation and sustainability of health insurance schemes.
5. Community Leaders: Advocate for the importance of health insurance and support community engagement initiatives.

Cost Items for Planning Recommendations:

1. Program Reinstatement and Strengthening: Budget for administrative costs, staff training, and capacity building.
2. Subsidized Premiums: Allocate funds for subsidizing premiums for eligible individuals to reduce financial barriers to enrollment.
3. Public Awareness and Education: Allocate resources for health promotion campaigns, community outreach programs, and educational materials.
4. Collaboration with Stakeholders: Budget for coordination meetings, workshops, and communication channels to facilitate collaboration among key stakeholders.
5. Monitoring and Evaluation: Allocate funds for data collection, analysis, and reporting to assess the impact and effectiveness of the health insurance programs.
Please note that the provided cost items are general suggestions and may vary based on the specific context and requirements of the health insurance program in Kwara State.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study design includes a mixed-methods approach, which provides a comprehensive understanding of the topic. The quantitative data was collected through a cross-sectional survey with a large sample size, and the qualitative data was obtained through in-depth interviews. The data was analyzed using appropriate statistical methods and thematic analysis. However, the study population consists of former enrollees and healthcare providers in a specific region of Nigeria, which may limit the generalizability of the findings. To improve the strength of the evidence, future studies could consider including a more diverse study population and conducting a longitudinal study to assess the long-term effects of the suspension of community-based health insurance.

Abstract

Study design and study population: in August 2018, about 2 years after the suspension of KCHIP (Figure 1), a mixed-method study was carried out among KCHIP former enrollees and healthcare providers in Kwara State, Nigeria. Using multi-stage random sampling, we recruited a total of 600 enrollees whose health insurance policy had expired at least 4 months before the end of December 2016. For the quantitative cross-sectional survey we obtain data on socio-demographics, healthcare utilization, enrolment status, health financial constraints and coping strategies since the suspension. Only adults (18 years and above) were included in the study, of whom a purposively selected 400 enrollees had accessed care in a KCHIP healthcare facility in the preceding 12 months. The remaining 200 participants were selected from those uninsured in the past 12 months. Of those 400 participants who have accessed healthcare, half (200) who had in addition to other health conditions been seeking chronic care, maternal care and care for acute conditions were included in the study. In-depth interviews (IDIs) were performed among 24 purposively selected former enrollees and among 29 health facilities´ managers of (19 public, 10 private) participating KCHIP facilities. The IDIs explored the effects of the programme suspension on both healthcare utilization by former enrollees and their coping mechanisms, and health facilities´ service provision. To be selected for the IDI, the participant must be above 18 years of age and must have utilized pertinent healthcare in the past 12 months. To obtain healthcare utilization pattern due to the programme suspension, health facilities´ clinical records were reviewed as part of the observation checklist tool developed for the qualitative data collection. Quantitative study: multi-stage sampling was used, selecting 5 Local Government Areas (LGAs): two from Kwara South, two from Kwara North and one from Kwara Central senatorial zones. Enrollees were selected randomly with the KCHIP enrollment database serving as sampling frame after allocating LGAs proportionate to constituent population sizes (total enrollment in the 5 LGAs in January 2016 was 73,438). An additional 30% was added from the sample frame for each LGA to cater for non-response and untraceable enrollees. The selected enrollees were traced in the community (with the help of community mobilizers) and interviewed by trained interviewers. The questionnaire captured data on respondents´ socio-economic characteristics, morbidity patterns, healthcare access and utilization in the preceding 12 months. Qualitative study: we conducted two rounds of IDIs among former enrollees and facilities´ managers. The enrollees´ interviews were conducted among 24 purposively selected adults across 9 selected LGAs cutting across the 3 zones of Kwara State. The selection of former enrollees into the IDIs was carried out in and around the health facilities using a pretested interview guide. The facility managers´ interviews were conducted in KCHIP facilities among the officers-in-charge (or the medical director). This comprised all 29 Enhanced Community Based Care (ECBC) health facilities (19 public, 10 private) spread across 9 LGAs; 13 health posts providing remote care services were excluded from the study because they were already linked to records of the 29 ECBCs. Data analysis:the quantitative data entry platform was designed using Open Data Kit® (ODK), while the data was entered using Kobo Toolbox® [14] and later exported to Statistical Package for Social Science (SPSS) version 22 for analysis. Simple logistic regression was used to explore the predictive factors of the financial constraints in the ability to pay for healthcare services after the programme suspension. The level of significance was set at a p-value of < 0.05 complemented with a 95% confidence interval (CI). Recorded qualitative interviews were transcribed and thematic analysis was carried out manually. Mixed results of the qualitative and quantitative data were triangulated and reported together to complement major contextual observations in this study. Ethics approval and consent to participate: written permissions were obtained from the ethics committee of the Kwara State Ministry of Health, Ilorin, Nigeria. Informed consent was obtained from the participants. Confidentiality of the participants´ and health facilities´ information were maintained.

Materials

N/A

Innovations

Based on the provided description, here are some potential innovations that could improve access to maternal health:

1. Mobile Health Clinics: Implementing mobile health clinics that travel to rural areas and underserved communities can provide access to maternal health services, including prenatal care, postnatal care, and family planning.

2. Telemedicine: Introducing telemedicine services can enable pregnant women to consult with healthcare providers remotely, reducing the need for travel and increasing access to medical advice and support.

3. Community Health Workers: Training and deploying community health workers who can provide basic maternal health services, education, and support within their communities can improve access to care, especially in remote areas.

4. Maternal Health Vouchers: Implementing a voucher system that provides pregnant women with financial assistance for maternal health services can help reduce financial barriers and increase access to quality care.

5. Public-Private Partnerships: Collaborating with private healthcare providers to expand maternal health services can help increase capacity and improve access, especially in areas with limited public healthcare facilities.

6. Health Education Programs: Developing and implementing health education programs that focus on maternal health can increase awareness, promote healthy behaviors, and empower women to seek appropriate care during pregnancy and childbirth.

7. Transportation Support: Providing transportation support, such as subsidized or free transportation services, can help pregnant women overcome geographical barriers and access healthcare facilities for prenatal and postnatal care.

8. Maternal Health Hotlines: Establishing dedicated hotlines staffed by trained healthcare professionals can provide pregnant women with immediate access to medical advice, information, and referrals.

9. Maternal Health Financing: Developing innovative financing mechanisms, such as microinsurance or community-based health insurance, specifically tailored for maternal health, can help reduce financial barriers and improve access to care.

10. Quality Improvement Initiatives: Implementing quality improvement initiatives in healthcare facilities that focus on maternal health can enhance the overall quality of care, leading to better health outcomes for pregnant women and their babies.

It’s important to note that the specific context and needs of the community should be considered when implementing these innovations to ensure their effectiveness and sustainability.

AI Innovations Description

Based on the information provided, the recommendation to improve access to maternal health would be to reinstate and strengthen the community-based health insurance program in Kwara State, Nigeria. This program was temporarily suspended in 2016, resulting in adverse consequences for healthcare utilization among enrollees.

To implement this recommendation, the following steps can be taken:

1. Policy and Program Reinstatement: The government should reinstate the community-based health insurance program and ensure its sustainability. This can be done by allocating adequate funding and resources to the program.

2. Expansion and Outreach: Efforts should be made to expand the program’s coverage and reach more communities, especially in rural areas where access to maternal health services may be limited. This can be achieved through targeted outreach campaigns and community mobilization.

3. Education and Awareness: Conduct education and awareness campaigns to inform the population about the benefits of the health insurance program, particularly in relation to maternal health. This can help address any misconceptions or barriers to enrollment.

4. Provider Engagement: Engage healthcare providers, both public and private, to participate in the program and ensure that they are adequately reimbursed for services provided to insured individuals. This can help improve the availability and quality of maternal health services.

5. Monitoring and Evaluation: Establish a robust monitoring and evaluation system to track the program’s impact on maternal health outcomes and financial protection. This will help identify any challenges or areas for improvement.

By implementing these recommendations, access to maternal health services can be improved, and financial constraints for pregnant women and new mothers can be reduced. This will contribute to better maternal health outcomes and overall well-being in Kwara State, Nigeria.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Reinstate and strengthen the community-based health insurance program: The temporary suspension of the community-based health insurance program in Kwara State, Nigeria resulted in financial constraints for enrollees. Reinstating and strengthening the program can help ensure financial protection and access to healthcare services, including maternal health.

2. Expand the coverage of health insurance schemes: To improve access to maternal health, it is important to expand the coverage of health insurance schemes to reach a larger population. This can be done by increasing funding, improving awareness and enrollment processes, and ensuring affordability for low-income individuals.

3. Enhance quality of care in healthcare facilities: The study mentioned that the high quality of care was a key factor that motivated former enrollees to continue utilizing program facilities even after the suspension. Investing in improving the quality of care in healthcare facilities, particularly in maternal health services, can attract more women to seek care and improve access.

4. Strengthen healthcare infrastructure: Adequate healthcare infrastructure, including well-equipped facilities and trained healthcare professionals, is crucial for improving access to maternal health. Investing in infrastructure development and capacity building can help ensure that women have access to the necessary facilities and skilled healthcare providers.

Methodology to simulate the impact of these recommendations on improving access to maternal health:

1. Define the target population: Identify the specific population group that will be the focus of the simulation, such as women of reproductive age or pregnant women in a particular region.

2. Collect baseline data: Gather data on the current status of access to maternal health, including healthcare utilization, financial constraints, and coping mechanisms. This can be done through surveys, interviews, and analysis of existing data sources.

3. Develop a simulation model: Create a mathematical or computational model that represents the healthcare system and the factors influencing access to maternal health. The model should incorporate variables such as health insurance coverage, quality of care, healthcare infrastructure, and financial constraints.

4. Define scenarios: Define different scenarios based on the recommendations mentioned above. For example, one scenario could simulate the impact of reinstating and strengthening the community-based health insurance program, while another scenario could simulate the effect of expanding health insurance coverage.

5. Input data and run simulations: Input the baseline data into the simulation model and run the simulations for each scenario. The model will generate outputs that show the potential impact of the recommendations on access to maternal health, such as changes in healthcare utilization, financial constraints, and coping mechanisms.

6. Analyze and interpret results: Analyze the simulation results to understand the potential effects of the recommendations on improving access to maternal health. Compare the outcomes of different scenarios to identify the most effective strategies.

7. Communicate findings and make recommendations: Present the findings of the simulation study, including the potential impact of the recommendations on access to maternal health. Use this information to make evidence-based recommendations for policymakers, healthcare providers, and other stakeholders involved in improving maternal health access.

Author

Dima Health

Identifiers:

DOI: 10.11604/pamj.2022.41.10.27978

Research Areas:

Community Interventions, Disparities, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants

Study Countries:

Nigeria

Study Design:

Cross Sectional Study, Grounded Theory

Study Approach:

Mixed-methods, Qualitative, Quantitative

Participants Gender:

Male