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Health Facility Surveys

Community-Based Health Insurance SurveysHealth Facility Surveys

Highlights of Final Reports from the Zones on the Feasibility Study for Community Based Health Insurance Scheme in Nigeria

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Prepared by Centre for Health Economics and Development (CHECOD) – National Health Insurance Scheme (NHIS) Lead Consulting Firm

Introduction

As part of preparation for the field work, a national technical workshop was organized for the development and harmonization of the tools, methodology, work plan and reporting format for the studies. During the workshop, each consulting firm made presentation on the methodology, data collection tools, reporting format, etc. To ensure quality in the process, a consultant from the National Bureau of Statistics (NBS) was invited to make a presentation on the standard methodology for sampling and to advice on the source and use of Enumeration Areas (EA) for the study. An interactive and plenary format was adopted for the workshop process with the participants breaking into groups with specific topics assigned to them to develop and subsequently present at plenary. Each group’s presentation at the plenary, were extensively discussed and the agreed outcomes were harmonized and adopted as the appropriate tools for the survey and reporting format for all zonal consulting firms.

Scope of Work in the 36 states plus FCT includes:
1. Compilation and analysis of background information on the: a. demographic, economic and social situation, b. financial institutions, and c. sources and levels of incomes of households in the study area for the feasibility of establishing Community Based Health Insurance Scheme (CBHIS);
2. Compilation and analysis of information on:
a. political factors, institutional and legislative framework in the study area
b. including information from relevant health authorities at State and Local governments;
3. Compilation and analysis of background information on the:
a. availability, supply and quality of health services in the study area for the feasibility of establishing CBHIS.
b. Conduct household surveys to estimate the target population’s willingness to pay,
c. evaluate the perceived quality of the health facilities,
d. ascertain people’s responses to illness in terms of the means of treatment sought, and their means of financing health expenses;
e. Compilation of other health and epidemiological data including analysis of the levels and patterns of utilization of health services,
f. health related expenditures based on existing data sources as well as other relevant information and health financing initiatives in the study area.
4. Compilation and analysis of likely administrative, transport, training, etc –costs associated with running the CBHIP in the study area;
5. Analysis of available sources of support (technical, financial administrative etc) for potential sustainability of the CBHIS;
6. Focal group discussion to determine the level of people’s confidence in the project’s Initiators and concept;
7. Collection of information on:
i. the level of social solidarity within the target population
ii. population’s knowledge and attitudes towards social solidarity and
iii. willingness to participate in prepayment schemes for health;
8. Based on information compiled under the scope of work, develop policy options for establishing CBHI Schemes that is adaptable to the local environment that will guide decision making to state and local stakeholders.

Highlights of Final Reports from the Zones
The feasibility studies on the CBHIS have been completed and details of the findings are contained in individual state reports. However, the highlights of the final reports from the zones are presented as follows:

North East Zone
The study report from Gombe state indicated that the proposed CBHIS project is feasible and desirable and would address the critical issues of prepayments, risk pooling and burden of out-of pocket. From the report about 76 per cent of the respondents were willing to participate in CBHIS. Furthermore of those who indicated willingness in contributing to CBHIS, more than half are ready to pay N400.

As for Taraba, the scheme is assessed to be feasible because 72 per cent of the respondents are currently paying for health care from personal sources – an indication of affordability and the potential to substitute risk pooling for out-of-pocket. In addition, the survey shows that about 31 per cent of the respondents are already covered by a form of contributory health care or the other, over 97 per cent of them are willing to enlist under the programme while over 50 and 18 per cent are willing to pay N200 and N400 respectively.

From Bauchi state, the report indicated that CBHIS is feasible in Gamawa LGA as over 97 per cent are willing to enlist for the programme when launched. The willingness to pay for CBHIS is further reinforced by more than 50 per cents of the respondents indicating their consent to pay N200 and over 28 per cent indicated they can pay N400. However, over 51 per cent them cannot afford medical services, whilst about 70 per cent will resort to external financial support if cost of services exceeded N2000. In addition, the out of pocket for medical expenses which is 66 per cent is unsustainable for the people whose majority live below the poverty line.

The Adamawa state report also indicated that the scheme is feasible based on the following results: 36 per cent of the respondents already have knowledge of CBHIS; 89 per cent are willing to contribute to the scheme when introduced; more than 45 per cent are willing to pay an amount that ranged from N200 to N500. Further information generated from the report include the following: out of pocket medical expenses is already more than 60 per cent; about 67.7 per cent of the respondents can presently afford medical services; approximately 7 percent cannot afford cost of treatment while 9 per cent will resort to external succor when cost of treatment is more than N2000.
Whatever the interpretation of the results from the report, the security situation in Adamawa needs to be address before contemplating on the next phase of the assignment.

The conclusion from the Yobe report indicated that establishment of CBHIS in the study area is feasible except for the acute security challenges in the area that may affect the stability and sustainability. While 18.33% of the respondents claimed to have prior knowledge of health insurance scheme, more than 66 per cent of respondents could bear the cost of medication indicating the potential for success if CBHIS is introduced. However, 79.84% respondents acknowledged their readiness to contribute to health Insurance Scheme and more than 52 per cent are willing to pay N200 premium. Finally, it is observed in the report that the state is so fragile as a result of the security challenges and as such so much would be required to prepare the pilot LGA for the launch of CBHIS there.

The report from Borno indicated security as a major threat to the establishment of CBHIS despite its feasibility. While more than 80 per cent of respondents could bear the cost of medication, 4.45 per cent relied on assistance from Community Solidarity groups indicating that there is already a form of risk pooling activities on going in the area. The conclusion as to the feasibility is further reinforced by information that 74.77% respondents acknowledged their readiness to contribute to health Insurance Scheme while more than 60 per cent are willing to pay between N200 and N400 premiums.
North Central Zone
The report from Abaji in FCT indicated that existence of various primary healthcare facilities that are owned by both public and private organizations which are manned by qualified medical personnel. Statistical analysis from the report shows that 96.3% of the responding households are willing to contribute in cash or in kind into a fund to help increase access to health care services. The preferred premium amount as indicated in the report is N200 per person per month. The distribution of the most preferred amount by responding households are N200 (43.7%). 15.1% are willing to pay N1,000, 9.8% indicated they would be willing to N400 and only about 7.7% are willing to pay N600 to obtain minimum benefits of the scheme.

Political factors, institutional and legislative framework in the FCT and the area council are conducive for the establishments of CBHI as informed by the quality and availability of healthcare facilities in the area council – both public and private are adequate and adjudged to be of good standard.

The state report from Nasarawa State revealed that healthcare facilities and medical personnel in the Akwanga LGA have to be upgraded and improved upon as pre-requisites for the establishment of CBHIS. Statistical evidence shows that 98.8% of the responding households are willing to contribute in cash or in kind into a fund to help increase access to health care services in this local government area. While the most preferred amount respondents are willing to pay per person per month to obtain the minimum benefits of the proposed scheme is N200 (65.3%); about 11.7% respondents are also willing to pay N500; 6.8% indicated they would be willing to pay N400 and only about4.8% indicated to pay N100. The majority of responding households used their own money (98.4%) when paying for treatment. The findings in the report are sufficient evidence that Akwanga Local Government Area could support the establishment of CBHIS after the necessary interventions in healthcare facilities and medical personnel by the state and local governments.
In the main report of Kwara State, Baruten Local Government Area has the potential of operating a CBHIS if the state and local governments have the necessary enablers in terms of upgraded public healthcare facilities. Statistical evidence revealed that majority of responding households used own money (99.2%) when paying for treatment while the competency of the medical staff was perceived to be adequate by 59.6% of the respondents. The report further shows that 85.5% of the responding households were willing to contribute in cash or in kind into a fund to help increase access to health care services. However, the report further indicated an average estimate of N200 per persons for average household size of 5 persons. The health workforce from the sampled healthcare facilities indicated inadequacy in terms of quality and quantity.

Kogi state report shows that Dekina Local Government Area is capable of accommodating the establishment the CBHIS based on approximately 81.6% of the responding households that were willing to contribute in cash or in kind into a fund to help increase access to health care services. However, the most preferred amount the responding households (53.2%) are willing to pay is N200 per person per month to obtain the minimum benefit package of the proposed scheme. The study proposed Anyigba which is the central location within the LGA as a possible location of CBHIS as it could be easily accessed by members of the community.

In the case of Benue state report, the analysis shows that 84.4% of the responding households were willing to contribute in cash or in kind an average of N200 into CBHIS. However, there is potential for affordability as the majority (98.4%) of the respondents used own money when paying for medical treatment. In order to ensure successful roll-out of the scheme, the quantity and quality of the healthcare facilities and personnel needs to be upgraded.

From Niger state report, the findings revealed that healthcare facilities and medical personnel in the Lavun LGA have to be upgraded and improved upon prior the establishment of CBHI. The report further shows that all (100%) the responding households in this local government area indicated their willingness to make some little contributions either in cash or in kind into a fund to help increase access to health care services. The most preferred amount the respondents would be willing to pay per person per month to obtain the benefits of the proposed scheme is N200 (50%) although about 27.2% also indicated that they would be willing to pay N400.
In addition, majority of the respondents financed their healthcare treatment with their personal money (83.5%), 63.8% indicated they borrowed money or took a loan while 48% of the respondents said they were financed through community solidarity or someone else paid the cost of treatment for them.

Finally, Plateau state report shows that 98% of the responding households indicated their willingness to make contributions either in cash or in kind into a fund while an average of N200 per person per month is the most preferred amount of premium for health services. Further findings in the report revealed that majority (85.6%) of the respondents financed their healthcare treatment with their personal money while 3.2% of the respondents said that they paid through community solidarity or someone else paid the cost of treatment for them. The existence of some level of social capital is an indication that the CBHIS might have relative acceptance in the communities

South East Zone
As it is indicated in the main report of Abia State, among the people that indicated willingness to contribute to CBHIS, 66.8% of them were ready to contribute N200, 16.7% were ready to pay N400, 8.9% were ready to pay N600, 0.9% were ready to pay N800 and 6.8% were ready to contribute N1000. However, in order to spur large proportion of people to contribute willingly and continuously to CBHIS in the State, the amount of money to be collected from them should not be more than N400; otherwise, government has to provide subsidy package for the people particularly the poor.

The information from the report of Anambra State showed that, among the respondents that showed willingness in contributing to CBHIS, 68.1% of them were ready to contribute N200, 11.3% were ready to pay N400, 1.4% were ready to pay N600, 3.4% were ready to pay N800 and 15.7% were ready to contribute N1000. However, the report recommended N300 as the maximum premium that should be charged in order to stimulate large percentage of people to contribute willingly and continuously.

The state report from Ebonyi State showed that, among the respondents that showed willingness in contributing to CBHIS, 73.3% of them said they would be able to contribute N200, 21.7% said they would be able to pay N400, 3.8% were ready to pay N600 and 1.2% were ready to contribute N1000. The implication of this is that 98.8% of all the respondents are ready to contribute between 200 Naira to 600 Naira.

The report from Enugu State indicated that among the respondents, who showed willingness in contributing to CBHIS, 52.2% of them were ready to contribute N200, 21.2% were ready to pay N400, 13.9% were ready to pay N600, 3.3% were ready to pay N800 and 9.5% were ready to contribute N1000. Therefore, in order to spur large number of people to contribute willingly and continuously to CBHIS in Enugu State, the amount of money to be collected from them should not be more than N350; otherwise, government has to provide a cushioning package of support for the people particularly the poor.

As indicated in the main state report of Imo State, among the respondents that showed willingness
in contributing to CBHIS, 46.6% of them were ready to contribute N200, 23.2% were ready to pay
N400, 10.1% were ready to pay N600, 6.2% were ready to pay N800 and 13.9% were ready to contribute N1000. This implies that 79.9% of all the respondents are ready to contribute between 200 Naira to 600 Naira. In order to encourage large enrollment and contribution to CBHIS in Imo State, the report recommended that the amount of money to be collected from them should not be more than N350; otherwise, government has to subsidize those who cannot afford the amount.

In conclusion, the south east zonal report advised NHIS to conduct public awareness on the insurance schemes in all the states before its implementation as this will increase public confidence in the scheme, especially after the failure of community-based health insurance programmes in the previous attempts.

North West Zone
From the final report of Kaduna State, it was shown that over 90% of households in all the wards in the LGA are willing to join the scheme. The average households (HHs) willingness to pay (WTP) is N328 while out-of pocket expenditure (86.6%) is the major source of household payment for healthcare. Only 0.2% of household members are covered by some form of health insurance scheme.

As for Jigawa State, the report shows that over 90% of households in all the wards in the LGA are willing to join the scheme. The average households (HHs) willingness to pay (WTP) is N115 while out-of pocket expenditure (85.4%) is the major source of household payment for healthcare. Only 8.7% of household members are covered by some form of health insurance scheme.

Kano State report revealed that 95.6% of households in all the wards in the LGA are willing to join the scheme. Furthermore, 85% of the respondents indicated out-of pocket expenditure as the major source of household payment for healthcare. The average households (HHs) willingness to pay (WTP) is N182.

In the case of Katsina State report, while over 97.4% of households in all the wards in the LGA are willing to join the scheme, only 1.1% of household members and 25% of patients interviewed in health facilities were covered by some form of health insurance scheme. . The average households (HHs) willingness to pay (WTP) is N75.80 while out-of pocket expenditure (79%) is the major source of household payment for healthcare.

The Kebbi State report revealed that over 93.6% of households in all the wards in the LGA are willing to join the scheme. . The average households (HHs) willingness to pay (WTP) is N108 while out-of pocket expenditure (66.1%) is the major source of household payment for healthcare. Only 0.2% of household members are covered by some form of health insurance scheme. However, the data shows that lack of quality service (7.8%), inadequate medical personnel (21.5%) and cost of services 14.9% were the prominent reasons of not using health facility among respondents.

In the case of Sokoto State, the report shows majority of members of households in all the wards in the LGA are willing to join the scheme. The average households (HHs) willingness to pay (WTP) is N288 while out-of pocket expenditure (96.9%) is the major source of household payment for healthcare. However, inadequate medical personnel (57.2%) and both attitude of health workers and lack of quality of services (11.8%) were prominent reasons of not using health facility among respondents. Only 1% of household members and 8.4% of patients interviewed in health facilities were covered by a health insurance scheme.

Finally in Zamfara state report, over 57.5% of households in all the wards in the LGA are willing to join the scheme. The average households (HHs) willingness to pay (WTP) is N110 while out-of pocket expenditure (96%) is the major source of household payment for healthcare. Only 0.3% of household members and 4.2% of patients interviewed in health facilities were covered by a health insurance scheme
South West Zone
Report from Osun state shows that willingness to accept the CBHI initiative was high with 97.15% indicating their interests in the Scheme. The study revealed that most of the households (91%) depended on high Out-of-pocket (OOP) expenditures for absorbing their healthcare costs. A simple and quick analysis showed average estimate amount of N366.67 as monthly willingness to pay (WTP) obtained from the submissions of the household heads. Based on financial feasibility estimation, a minimum of 50–member enrolment with minimal adverse selection is required for the scheme to survive in administering a basic services package to members. The economic, social and technical data from each of these target population areas – Ajido, Alaka, Faforiji and Iperindo – all show that they have homogeneous and crucial mass of co-inhabitants which seem to possess some reasonable potentials to start the CBHIS in the LGA.

From Ekiti State, most of the interviewed respondents (92.4%) expressed their excitement and readiness to embrace community based health insurance initiatives having perceived that it could minimize individual household financial risks in the event of illnesses. The report revealed that about 91.6% of the households depended on high Out-of-pocket (OOP) expenditures for absorbing their healthcare costs. A simple analysis in the report showed average estimate amount of N400 as monthly WTP obtained from the submissions of the household heads. Similarly, Aramoko, Erijinyan, Oke-Imesi, Erio and Iponle-Iloro have homogeneous and crucial mass of co-inhabitants that would facilitate the establishment of CBHIS in the LGA.

Ondo state report shows that 95.15% of the respondents indicate their interests to contribute to the Scheme. The average monthly WTP is N330 while 88.4% of the respondents depended on high Out-of-pocket (OOP) expenditures for absorbing their healthcare costs.
Given the interests exhibited by those interviewed at Ile-Oluji, Oke-Igbo, Farm Settlement and Onipanu, it may be concluded that many of the target population groups are eager to host the scheme in their communities.

In the case of Ogun State report, the willingness to join/contribute to the CBHI initiative was high with 99% indicating their interests in the Scheme. Furthermore, 97% of the respondents use their own money for absorbing healthcare costs. The average WTP is N305 for the LGA and this could be applied to each of the target population (Shagamu, Ogijo Shagamu, Ogere and Makun Shagamu) within the LGA because the WTP ratios observed amongst all the target population clusters do not have large deviation from the mean figure. Based on the available statistics, majority of the rural households are likely to accept CBHI as a mechanism that would remove financial barriers to access health care.

Finally, Oyo state report shows that willingness to accept the CBHI Initiative was high with 96.2% indicating their interests in the Scheme. While most (80%) of the households depend on high Out-of-pocket (OOP) expenditures for absorbing their healthcare costs, the report indicated monthly average WTP of N350. The socio-economic potentials of community members are average while economic, social and technical characteristics of the target population areas – Central Ogbomosho, Sabo Ogbomosho, Igbo Agbonyin and Saja Ogbomosho – show homogeneous and crucial mass of co-inhabitants which seem to possess some reasonable potentials to start the CBHIS in the LGA.

Lagos State
In Ajeromi local government area, households (heads 23.9%, with children 50.5% and with spouse 17.9%) that were willing to contribute accounted for cumulative of 92.3% of the respondents and with payment between N198.10 and N752.30 which is translated into a mean amount of N475.90 by taking into consideration of 95% confidence interval irrespective of the household size.

For Lagos mainland local government area, household heads with their own children accounted for 49.5% while those with spouse showed 16.7% of the respondents respectively. Households (heads 24.9%, with children 49.5% and with spouse 16.7%) that were willing to contribute accounted for cumulative of 91.1% of the respondents and with payment between N136.80 and N491.80 which is translated into a mean amount of N314.30 by taking into consideration of 95% confidence interval irrespective of the household size.

In the case of Shomolu local government area, household heads with their own children accounted for 47.1% while those with spouse showed 18.6% of the respondents respectively. Households (heads 28.4%, with children 47.1% and with spouse 18.6%) that were willing to contribute accounted for cumulative of 94.1% of the respondents and with payment between N292.70 and N917.80 which is translated into a mean amount of N605.30 by taking into consideration of 95% confidence interval irrespective of the household size.

Fromm the study reports Lagos State has the enabling environment to accommodate the operation of CBHIS. These are based on the following:

1. The state has flagged off four (4) different pilot mutual health insurance schemes in various communities and so far these have been very successful;
2. The existence of organized and capable community that needs some form of health insurance coverage to protect them from high medical costs;
3. The availability of a legal and representative body, such as CSOs/NGOs that will act as technical facilitators to manage the CBHIS;
4. A network of providers who are willing to link up with the insurance scheme and can be contracted to provide quality health care at reasonable costs; and
5. A supportive government policy and health programme

To succeed however, some enabling factors need to be in place:
1. More awareness, sensitization and marketing among the communities;
2. A product that is affordable and acceptable to the community;
3. Technically and financially sound technical facilitators that can administer the CBHIS as well negotiate effectively with the providers and can interface with the communities.
4. An effective MIS that monitors the programme closely and makes midterm corrections where necessary.

South South Zone

The results of the survey show that the roll-out of CBHIS in the selected communities in the South-South Zone of the country are technically feasible, financially viable and politically worthwhile and can be sustained on a continuous basis.

The report from Essien Udim in Akwa Ibom State shows that there is a high demand for CBHI with 99% of the respondents showing their willingness to join/contribute. These high levels of interest among the respondents to participate in the scheme were influenced by household characteristics, such as education, occupation, household size and age group, health status and household expenditure. The mean WTP per person per month was found out to be 269.0 ± 123 naira. This is an equivalent of 4, 704 naira per person per year with an average household size of 4 members. In addition, majority (96%) of the households financed their treatment out-of-pocket (own money) and the mean monthly household expenditure was found to be 30,920 ± 5845 naira which indicates a level of ability to pay and affordability to pool resources together that will ensure sustainability of the scheme.

From Bayelsa State report, 91% of the households interviewed expressed their high optimism to embrace the scheme when established. The mean WTP per person per month was found out to be 466± 222 naira. This is an equivalent of 5,592 naira per person per year with an average household size of 4 members. Another influential factor to support the establishment of CBHIS is the 94% of the households interviewed that financed their treatment from out-of-pocket (own money). Additionally, the mean monthly household expenditure was found to be 11,853± 2240 naira which indicates potentials for affordability and sustainability of the scheme.

In the case of Delta State reports, it was revealed that there is a high demand for CBHI with 93% of the respondents showing their willingness to join/contribute. The mean WTP per person per month was found out to be 682.30 ± 281 naira. This is an equivalent of 8,187 naira per person per year with an average household size of 4 members. While the majority (95%) of the households financed their treatment out-of-pocket (own money), the mean monthly household expenditure was found to be 12,400 ± 2237 naira indicating the possibility of being able to pool resources within the communities to ensure sustainability of the scheme.

Also, in Cross River State report, 97% of the respondents indicated their willingness to join/contribute which is a reflection of their interest in CBHIS. The mean WTP per person per month was found out to be 271.40 ± 116 naira. This is an equivalent of 3, 256 naira per person per year with an average household size of 4 members. Furthermore, majority (85%) of the households financed their treatment out-of-pocket (own money) while the mean monthly household expenditure was found to be 18,524 ± 3402 naira. From the available data, the communities have demonstrated some positive characteristics in terms of their ability to pay in order to ensure that the pool of fund will be adequate to sustain the scheme.

Similarly, Edo State reports revealed the readiness of the respondents to embrace the CBHI scheme as 93% of the respondents showed their willingness to join/contribute. In addition, the interest is also reinforced by household characteristics, such as level of education, occupation, household size and age group, health status and household expenditure. The mean WTP per person per month was found out to be 644 ± 230 naira. This is an equivalent of 7,728 naira per person per year with an average household size of 4 members. Majority (85%) of the households financed their treatment out-of-pocket (own money) while the mean monthly household expenditure was found to be 16,816.70 ± 6869 naira.

Finally in Rivers State reports, the interest in CBHI is high with 97% of the respondents showing their willingness to join/contribute. The mean WTP per person per month was found out to be 562.80 ± 379 naira. This is an equivalent of 6,744 naira per person per year with an average household size of 4 members. The mean monthly household expenditure was found to be 33,262 ± 6,038 naira which indicates high household economic profile of the communities and the potential to be able to afford paying for the scheme if it is eventually establish.

In conclusion, the people of the South-South Zone believe in communal living and social bonding which means that they have the affinity to form associations such as cooperatives, unions and other social groupings. This demonstrates the existence of established social capital and community structures which can facilitate the establishment of a sustainable/viable Community-Based Social Health Insurance Programme.
General Recommendation from the Reports

In moving forward, the success of establishing the schemes across all the zones would depend on addressing the following challenges:
1. Funding for the public health facilities;
2. Low per capita income and poverty generally amongst the critical portion of the population;
3. Poor infrastructure: poor and / or non-existent roads and distance to communities which limit access of respondents to facilities and to communities.
4. Provision of medical supplies, training of staff, etc;
5. More awareness, sensitization and marketing among the communities: There is limited awareness on the potentials of CBHIS.
6. Inadequate quantity and quality of health workforce;
7. Security issues that has increased the population of internally displaced persons (IDP)

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