Willingness to pay for haemodialysis among patients with chronic kidney disease in Abuja, Nigeria.

BACKGROUND: Evidence of willingness to pay for kidney replacement therapy is scarce in low-middle-income countries, including Nigeria's Formal Sector Social Health Insurance Programme. The study, therefore, assessed the willingness to pay for haemodialysis among chronic kidney disease patients in Abuja, Nigeria. METHODS: The study adopted a cross-sectional survey design. We used the contingent valuation method to estimate the maximum stated willingness to pay (WTP) for haemodialysis among end-stage kidney disease (ESKD) patients. We obtained informed written consent from respondents before data collection. The socio-demographic characteristics and willingness to pay data were summarized using descriptive statistics. We evaluated the mean differences in respondents' WTP using Mann-Whitney and Kruskal-Wallis tests. All variables that had p < 0.25 in the bivariate analysis were included in the Generalized Linear Model (gamma with link function) to determine the predictors of the WTP for one's and another's haemodialysis. The level of significance in the final model was ρ < 0.05. RESULTS: About 88.3% and 64.8% of ESKD patients were willing to pay for personal and altruistic haemodialysis, correspondingly. The mean annual WTP for haemodialysis for one's and altruistic haemodialysis was USD25,999.06 and USD 1539.89, respectively. Private hospital patients were likelier to pay for their haemodialysis (ß = 0.39, 95%CI: 0.21 to 0.57, p < 0.001). Patients attending public-private partnership hospitals were less likely to pay for altruistic haemodialysis than those attending public hospitals (ß = -1.65, 95%CI: -2.51 to -0.79, p < 0.001). CONCLUSIONS: The willingness to pay for haemodialysis for themselves and others was high. The type of facility ESKD patients attended influenced their willingness to pay for haemodialysis. The findings highlight the need for policies to enhance affordable and equitable access to haemodialysis in Nigeria through pre-payment mechanisms and altruistic financing strategies.

Economic Burden of Diabetes and Hypertension: A Study of Direct and Indirect Cost of Treatment in Southeast Nigeria.

The prevalence of diabetes mellitus and hypertension is increasing yearly in many low- and middle-income countries such as Nigeria. The increasing burden of these noncommunicable diseases has led to an increase in the overall cost of health care. This study aimed at determining the direct and indirect health care costs of diabetes mellitus and hypertension occurring both singly and in co-morbidity. The study was undertaken in the Enugu State University Teaching Hospital (a tertiary hospital) in Enugu State, Southeast Nigeria. Data were collected using a pre-tested questionnaire. Out of 817 patients interviewed, 37% had only diabetes mellitus, 35% had hypertension, and 28% had both diabetes mellitus and hypertension in co-morbidity. Direct costs of treating diabetes mellitus and hypertension in the month before the survey were $28.40 and $19.35, respectively, while the indirect costs of treatment in the month before the study were $7.36 and $5.51, respectively. Direct and indirect costs for diabetes mellitus and hypertension in co-morbidity were $37.00 and $4.62, respectively. A concentration index showed that diabetes mellitus and hypertension were more evident among the poor than the rich. The economic cost when compared with patients' income revealed that >25% of their income is spent monthly on health care.

Who benefits from tuberculosis outpatient services in Enugu state, Nigeria? A benefit incidence analysis.

OBJECTIVES: Nigeria is one of the 30 high-burden countries for TB and currently, recurrent costs of TB treatment services are largely dependent on donor-funding, with government providing the health facilities. This study aims to assess the benefit incidence of TB treatment services so as to determine if the poor and rural dwellers preferentially benefit from such services that were subsidized by government and donors. METHODS: A survey of patients (n = 202) accessing TB treatment services was conducted between 2019 and 2020 in five purposively selected rural and urban health facilities in Enugu state. Socio-economic status (SES) was estimated using household assets ownership. Benefits of TB services were measured by multiplying the unit cost of utilization of different services while the net benefit was calculated by subtracting out-of-pocket (OOP) payments incurred from the benefits. We estimated the benefit for 1 month and the benefit for the whole TB treatment course (6 months). Concentration index was used to determine the level of equity in spending across the socio-economic quintiles. RESULTS: 56.4% of the respondents were from urban facilities. 100% had used TB drugs in the past months, 73% had undergone a Gene-Xpert test, and 67% had had a consultation. All patients received TB drugs without OOP payment, but 90% paid for X-ray. Urban respondents captured a disproportionally higher share of benefit from TB services. The concentration index was -0.025 for net benefit from TB services across different quintiles, indicating the pro-poor distribution of TB services in Nigeria. CONCLUSIONS: The benefit from TB services had a pro-poor distribution, but urban respondents obtained a disproportionally higher share of gross and net benefit from TB services. Funding for TB services needs to be secured to promote the equitable access to TB services.

Examining healthcare purchasing arrangements for strategic purchasing in Nigeria: a case study of the Imo state healthcare system.

BACKGROUND: Strategic healthcare purchasing (SHP), as a critical function of health financing, enhances the optimal attainment of health system goals through the efficient use of financial resources. Countries committed to universal health coverage (UHC) have made progress towards strategic purchasing through relevant reforms in their healthcare financing systems. This study examined the purchasing arrangements and practices in the Imo state healthcare system to track progress towards SHP committed to UHC. METHODS: A critical review and analysis of healthcare financing schemes in Imo state, south-eastern Nigeria, was undertaken to assess their purchasing practices based on a descriptive qualitative case study approach. Relevant documents were collected and reviewed including in-depth interviews with stakeholders. Information was collected on external factors and governance, purchasing practices and other capacities of the state's health financing schemes. The analytical framework was guided by comparing purchasing practices of the financing schemes with the ideal strategic purchasing actions (SPAs) developed by RESYST (Resilient and Responsive Health Systems), based on the three pairs of principal-agent relationships. RESULTS: Healthcare purchasing in the state is dominated by the State Ministry of Health (SMOH) using a general tax-based and public health system, making government revenue a major source of funding and provision of healthcare services. However, purchasing of health services is passive and the stewardship role of government is significantly weak, characterized by substantial insufficient budgetary allocations, inadequate infrastructure and poor accountability. However, the health benefit package significantly reflects the needs of the population. As an integrated system, there is no purchaser-provider split. Provider selection, monitoring and payment processes do not promote quality and efficiency of service delivery. There is very limited institutional and technical capacity for SHP. However, the state recently established the Imo State Health Insurance Agency (IMSHIA), a social agency whose structure and organization support SHP functions, including benefit packages, provider selection processes, appropriate provider payment mechanisms and regulatory controls. CONCLUSION: Healthcare purchasing in Imo state remains mostly passive, with very limited strategic purchasing arrangements. The main challenges stem from the entrenched institutional mechanism of passive purchasing in the government's health budgets that are derived from general tax revenue, lack of purchaser-provider split, and poor provider payment and performance monitoring mechanisms. The establishment of the social insurance agency represents an opportunity for boosting SHP in the state for enhanced progress towards UHC. Building capacity and awareness of the benefits of SHP among policy-makers and programme managers will improve the efficiency and equity of health purchasing in the state.

Examining the distribution of benefits of a free Maternal and Child Health programme in Enugu State, Nigeria: a benefit incidence analysis.

OBJECTIVE: To determine the population groups that benefit from a Free Maternal and Child Health (FMCH) programme in Enugu State, South-east Nigeria, so as to understand the equity effects of the programme. METHOD: A community-based survey was conducted in rural and urban local government areas (LGAs) to aid the benefit incidence analysis (BIA) of the FMCH. Data were elicited from 584 randomly selected women of childbearing age. Data on their level of utilisation of FMCH services and their out-of-pocket expenditures on various FMCH services that they utilised were elicited. Benefits of the FMCH were valued using the unit cost of providing services while the net benefit was calculated by subtracting OOP expenditures made for services from the value of benefits. Costs were calculated in local currency (Naira (₦)) and converted to US Dollars. The net benefits were disaggregated by urban-rural locations and socio-economic status (SES). Concentration indices were computed to provide the level of SES inequity in BIA of FMCH. RESULTS: The total gross benefit incidence was ₦2.681 million ($7660). The gross benefit that was consumed by the urban dwellers was ₦1.581 million ($4517.1), while the rural dwellers consumed gross benefits worth ₦1.1 million ($3608.20). However, OOP expenditure for the supposedly FMCH was ₦6 527 580 (US$18 650.2) in the urban area, while it was ₦3, 194, 706 (US$ 9127.7) among rural dwellers. There was negative benefit incidence for the FMCH because the OOP exceeded the gross benefits at the point of use of services. There was no statistically significant difference in the benefit incidence and OOP expenditure between the urban and rural dwellers and across socio-economic groups. CONCLUSION: The distribution of the gross benefits of the FMCH programme indicates that it may not have achieved the desired aim of enhanced access particularly to the low-income population. Crucially, the high level of OOP erased whatever societal gain the FMCH was developed to provide. Hence, there is a need to review its implementation and re-strategise to reduce OOP and achieve greater access for improved effectiveness of the programme.

OBJECTIF: Déterminer les groupes de population qui bénéficient d'un programme de santé maternelle et infantile gratuite (F-MCH) dans l'Etat d'Enugu, dans le sud-est du Nigéria, afin de comprendre les effets du programme sur l'équité. MÉTHODE: Une enquête communautaire a été menée dans des zones locales gouvernementales (ZLG) rurales et urbaines pour faciliter l'analyse de l'incidence des bénéfices (AIB) du F-MCH. Des données ont été obtenues auprès de 584 femmes en âge de procréer sélectionnées aléatoirement. Les données sur leur niveau d'utilisation des services F-MCH et leurs dépenses directes de la poche (DDP) pour divers services F-MCH qu'elles ont utilisé ont été obtenues. Les bénéfices du F-MCH ont été évalués en utilisant le coût unitaire de la prestation des services, tandis que le bénéfice net a été calculé en soustrayant les dépenses directes de la poche pour les services de la valeur des bénéfices. Les coûts ont été calculés en monnaie locale (Naira ₦) et convertis en dollars américains USD. Les bénéfices nets ont été ventilés par endroits urbain-rural et par statut socioéconomique (SSE). Les indices de concentration ont été calculés pour fournir le niveau d'iniquité du SSE dans l'AIB du F-MCH. RÉSULTATS: L'incidence des prestations brutes totales était de ₦ 2.681.000 (7.660 USD). Le bénéfice brut qui a été consommé par les habitants des villes était de ₦ 1.581.000 (4.517,1 USD), tandis que les habitants ruraux ont consommé une valeur de bénéfices bruts de ₦ 1,1 million (3,608.20 USD). Cependant, les DDP pour le soi-disant F-MCH étaient de 6.527.580 ₦ (18.650,2 USD) dans la zone urbaine, alors qu'elles étaient de 3 194 706 ₦ (9.127,7 USD) parmi les habitants des zones rurales. Il y avait une incidence négative des bénéfices pour le F-MCH parce que les DDP dépassaient les bénéfices bruts au point d'utilisation des services. Il n'y avait pas de différence statistiquement significative dans l'incidence des bénéfices et les DDP entre les habitants des zones urbaines et rurales et entre les groupes socioéconomiques. CONCLUSION: La répartition des bénéfices bruts du programme F-MCH indique qu'il n'a peut-être pas atteint l'objectif souhaité d'un accès amélioré, en particulier pour la population à faible revenu. Fondamentalement, le niveau élevé de dépenses directes de la poche a effacé tout gain sociétal que le F-MCH avait été développé pour fournir. Par conséquent, il est nécessaire de revoir sa mise en œuvre et de revoir sa stratégie pour réduire les DDP et obtenir un meilleur accès pour une efficacité accrue du programme.

The roles of health maintenance organizations in the implementation of a social health insurance scheme in Enugu, Southeast Nigeria: a mixed-method investigation.

BACKGROUND: In Nigeria, health maintenance organizations (HMOs) are the purchasers of health insurance with a social National Health Insurance Scheme for civil servants. However the roles of HMOs in implementation of social health insurance are not clear. This study determined the roles of HMOs in implementation of the national social health insurance scheme in Enugu, Southeast Nigeria. METHODS: A partially mixed sequential dominant status design was employed in the study. Quantitative data were collected from 613 Federal Government employees that are registered with the National Health Insurance Scheme (NHIS) as part of the Formal Sector Social Health Insurance Program (FSSHIP) using an interviewer-administered questionnaire. Test for sampling adequacy was ensured (KMO, 0.701) and likewise the sphericity of the data using Bartlett's test (Chi [1] 796.72, p-value < 0.001). For the qualitative study, there was document review and in-depth interviews. A total of 28 in-depth interviews were conducted with key stakeholders comprising of managers of HMOs, NHIS manager, providers of health care and personnel in the State Ministry of Health among others. Thematic analysis was used for the qualitative data. RESULTS: One-third (31.5%) of respondents said that roles of HMOs were very important, while 23% said that their roles were not important. More than half (57.70%) ranked HMOs very low in their roles, while 24.10% ranked them highest. Concentration index shows that the poor were satisfied (-.10), while the rich were highly satisfied (0.13) with roles of HMOs. The qualitative data analysis showed that most of the respondents were not satisfied with the roles of HMOs based on the themes that were developed and analyzed. CONCLUSION: There is clear understanding of the functions of HMOs among respondents in the study although they generally think that HMOs are not meeting the expectations of the scheme. There is need for the Federal Government through the National Health Insurance Scheme to provide more effective guidelines for HMOs, supervise and monitor the implementation of such guidelines for HMOs to improve on their roles.

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

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

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

BACKGROUND: 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. METHODS: 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. RESULTS: 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 CONCLUSIONS: 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.

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 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.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.