International Journal of Medicine and Health Development

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 24  |  Issue : 2  |  Page : 70--77

Investigating the level of awareness and extent of financial risk protection among the population in Enugu state, southeast Nigeria


Chijioke Okoli, Eric Obikeze, Charles Ezenduka, Ejikeme Arodiwe, Ogbonnia Ochonma, Obinna Onwujekwe 
 Department of Health Administration and Management, Faculty of Health Sciences and Technology, College of Medicine, University of Nigeria, Enugu state, Nigeria

Correspondence Address:
Mr. Chijioke Okoli
Department of Health Administration and Management, Faculty of Health Sciences and Technology, College of Medicine, University of Nigeria, Enugu Campus, Enugu state
Nigeria

Abstract

Objective: The study investigated the level of awareness and extent of financial risk protection among the population in Enugu state, southeast Nigeria. Materials and Methods: A mixed-method approach involving cross-sectional quantitative and qualitative methods was adopted for data collection and analysis. The study was conducted in two purposively selected urban and rural local government settings in Enugu North and East senatorial zones, respectively. Results: The quantitative results show that most of the respondents (77.1%) were women and 80.2% were married. Slightly above a quarter of the respondents (25.6%) were self-employed, whereas 29.1% were main income earners. Out-of-pocket (OOP) dominates payment mechanisms (94.9%), whereas more than half (54.4%) of the respondents went to patent medicine dealers for treatment in the last one month. Logistic regression shows overall significance in use of prepayment mechanisms with χ2 = 56.57 and P = 0.001. More so, finding indicates that 55.9% of respondents have heard of prepayment mechanisms mainly from television (30.4%) and radio program (20.2%), while 89.5% has not used any prepayment mechanism in the State. Conclusion: OOP still dominates payment mechanism in Enugu state. Although over half of the respondents (55.9%) have heard of prepayment mechanisms, approximately 90% has not used any prepayment mechanism in the State. This calls for policy that will ensure moving away from OOP payment to prepayment mechanism through health system strengthening and awareness creation for the populace.



How to cite this article:
Okoli C, Obikeze E, Ezenduka C, Arodiwe E, Ochonma O, Onwujekwe O. Investigating the level of awareness and extent of financial risk protection among the population in Enugu state, southeast Nigeria.Int J Med Health Dev 2019;24:70-77


How to cite this URL:
Okoli C, Obikeze E, Ezenduka C, Arodiwe E, Ochonma O, Onwujekwe O. Investigating the level of awareness and extent of financial risk protection among the population in Enugu state, southeast Nigeria. Int J Med Health Dev [serial online] 2019 [cited 2020 Aug 15 ];24:70-77
Available from: http://www.ijmhdev.com/text.asp?2019/24/2/70/271081


Full Text



 Introduction



Providing citizens or the populace with financial risk protection and enhanced access to health care is a growing priority for low- and middle-income countries (LIMCs).[1] Limited progress toward universal health coverage (UHC) has been made especially in African countries where there is generally a heavy reliance on out-of-pocket (OOP) payments, with some countries such as Cameroon, Guinea, and Nigeria funding 70% or more of total health-care expenditure through OOP.[2] UHC cannot be achieved by weak systems where more than 65% of health-care financing comes from OOP payments, thereby impoverishing poor households.

OOP payment is arguably the most significant barrier to access and the source of financial impoverishment.[3] Thus, in order to avoid and/or reduce reliance on direct payments, governments need to encourage the risk pooling and prepayment.[3],[4] Prepayments allow funds to be pooled so that it can be redistributed to reduce financial barriers for those who need to use services they could not otherwise afford.[5] It is necessary for income and risk-cross subsidies.[6],[7],[8] Evidence shows that no any country in the world has achieved anything close to UHC using voluntary insurance as primary financing mechanism.[8] UHC ensures access to and use of quality health-care services by all citizens and protection from catastrophic financial effect of ill health.[9] Achievement of UHC can be facilitated when political will and economic factors are put in proper perspective in the health system.

The goal of UHC is to ensure that all people obtain the health services (prevention, promotion, treatment, rehabilitation, and palliation) they need without the risk of financial impoverishment.[5] Nonetheless, every year over 150 million people worldwide face catastrophic health-care costs because of direct payments, whereas 100 million are pushed into poverty because they are required to pay OOP.[5],[8],[10],[11] It was shown that 233,000 deaths of children under the age of 5 could be prevented every year by removing user fees/OOPs in 20 African countries.[8],[12]

Financial risk protection especially among the low income and poor is crucial because most of them sell their assets, borrow money, withdraw children from school, young kids are forced to work to support the family, and the poverty cycle continues from generation to the next generation.[13] So to break the cycle, financial risk protection is critical and should be a priority item on the health-care financing agenda.[14],[15]

In the quest to achieve UHC, the Federal Government of Nigeria established the National Health Insurance Scheme (NHIS) in 1999.[16] Currently, the NHIS covers only federal government employees and the coverage level is less than 5% of the general population instead of the World Health Organization recommended 90%.[15]

In Enugu state, Nigeria, financial risk protection for health care is lacking and the most affected are the rural dwellers and the poorest.[15] Although the state adopted formal sector social health insurance program in 2010, only free maternal and child health (MCH) services are operational.[17] Hence, this study aims at investigating the level of awareness and use of universal financial risk protection by the populace as health insurance is typically based on prepaid mechanism.[17] Findings may provide policy relevant information for uptake of prepayment mechanism and thereby contain inherent catastrophic spending and impoverishment associated with OOP payment. The long-term goal is to ensure that every household resident in Enugu state has financial risk protection in accessing health-care services.

 Materials and Methods



Study area

The study was conducted in Enugu state, southeast Nigeria, with population of 4.3 million as at 2016.[18] Administratively, the State is divided into 17 local government areas (LGAs) and 3 senatorial zones comprising Enugu North, Enugu East, and Enugu West Senatorial zones.[19] In the State, there are three levels of health-care delivery, namely primary, secondary, and tertiary. The State has three federal tertiary hospitals and one state tertiary hospital. Moreover, 896 health facilities, 513 public facilities, 348 private facilities, and 35 faith-based facilities, exist in the State. Some of the public health facilities, especially primary health centers (PHCs), are in a state of disrepair.[18]

Most of the working population (78%) is self-employed.[19] Urban dwellers are mostly civil servants, traders, transporters, or artisans, whereas rural dwellers are mainly subsistence farmers or petty traders.[20] A small proportion of the population is engaged in manufacturing activities, although the state has a well-developed commercial and financial center.[21] In total, 95% are of Igbo speaking tribe and about 59% lives in the rural areas.[22] Christianity is the predominant religion in the State.[19]

Study design

The study adopted a mixed-method study design involving cross-sectional quantitative (questionnaire) and qualitative (in-depth interview [IDI]) methods. The study was conducted in two purposively selected urban and rural LGAs, namely Enugu North and Enugu East, respectively. The two LGAs were selected due to convenience, because the key informants are resident in Enugu metropolis located in both urban (Enugu North) and rural (Enugu East) LGAs.

Sample size/sampling

A sample size of 800 was determined using the minimum sample size for estimating a population proportion when assuming random sampling from a large population. The formulae n = P(1 – P)Z2/d2 were used, where P = 0.50 (anticipated proportion) and d = 0.05 (precision). Initially, a sample size of 384 was achieved. To accommodate for nonresponse rate and ensure robust result, we decided to increase the total sample size to 800. This is because the higher the sample size the better the outcome. More so, the computed sample size is the minimum; there is no hard-and-fast rule about the extent that it can be increased to given that representativeness is more important than sample size.[23] Ten questionnaires (five per LGA) were pretested in the two LGAs and outcome was used to update the final questionnaire before embarking on fieldwork.

Of 17 key informants/respondents purposively selected from Ministry of Health, State Health Board, State Primary Health Development Agency, Cottage Hospital, PHC, House of Assembly Committee on Health and NHIS desk officer, 12 key informants were interviewed, whereas 5 informants could not be interviewed because of office exigencies. The interviews focused on prepayment mechanisms in the state that ensures citizens' access to health care without payment at the point of care. Each interview lasted for about 30min. Probes were used to elicit detail information on emerging issues. All the 12 IDIs were undertaken in May 2017. Four pairs of researchers from Health Administration and Management Research Group (HAMReG) conducted the IDIs. All the IDIs were conducted in the various respondents' office in Enugu. Interviews were audiotaped with consent of the respondents. The recorded interviews were transcribed verbatim into Microsoft Word 2016 (Redmond, Washington, DC, USA) for analysis. To ensure high-quality transcription, all of the transcriptions were individually checked against the original audio-recordings.

Data analysis

Quantitative data were double entered in EPI-Info and analysis was performed using Stata/SE-13 software (StataCorp, College Station, TX, USA) to generate descriptive statistics and cross-tabulation. For the qualitative process, all the interviews were transcribed and imported into NVivo 11.3.0.773 QSR International Pty Ltd (Melbourne, Australia) for data arrangement. The transcripts were read to identify main themes in the responses provided by the respondents. The themes include existing prepayment mechanisms in the state, enabling economic and political factors, constraining economic and political factors, and actors in the state. These themes provided the basic coding structure.

Ethical considerations

Ethical approval was obtained from the Ethics Committee of the University of Nigeria Enugu Campus. A signed informed consent was obtained from each of the participants and they were assured of anonymity and confidentiality.

 Results



Quantitative result

[Table 1] shows the socioeconomic and demographic characteristics of respondents. Most of the respondents (77.1%) were women, and 80.2% were married with an average of five persons per household. The respondents' highest education levels were polytechnic/university (27.2%) and primary school (11.7%), whereas 4.7% had no formal education. A quarter of the respondents (25.6%) were self-employed in their business/enterprise, 13.5% were engaged in petty trading, and 13.1% were employed in the private sector. Up to 11.8% of the respondents are employed in the public sector. Most respondents (70.9%) were not main income earners in terms of household expenditure.{Table 1}

Respondents' awareness of financial risk protection

[Table 2] shows that 55.9% of respondents have heard of prepayment mechanisms mainly from television (30.4%) and radio program (20.2%), whereas 89.5% has not used any form of prepayment mechanism in the State.{Table 2}

On the other hand, IDI findings with health insurance desk officer on awareness of a prepayment mechanism in the State observed that:

“As far as I know, awareness is something that is very important in the insurance scheme, but the way I’m observing people and given the number of people getting enrolled……, people are ----turning up gradually but I still have to say that the message has to be carried to the hinterlands. Because they are not aware that there is a programme where people’s fund are pooled together for healthcare provision and one can access healthcare without payment at the point of service. So of paramount importance in my estimation is education, awareness and of course good management of the funds… so that funds can be well managed and not diverted.” (IDI-02)

[Table 3] presents the distribution of sources of information about health insurance for respondents according to socioeconomic characteristics. It shows that for every source, there are more women than men who have heard about health insurance; from the radio, TV, relations, church or hospital, respectively. Vast majority of married respondents (over 80%) are the most informed through any of the sources.{Table 3}

By occupation, public servants are most informed through the radio (23%) and television (25%), whereas the self-employed are the most informed through their relatives (32%)

[Table 4] examines the payment mechanisms used by respondents and forms of payment at the health facilities. Majority (95%) of the respondents used OOP to settle their health bills at the facilities. Moreover, findings from IDI on existence of prepayment mechanism in the State notes that:{Table 4}

“there is no pre-payment mechanism in the state that ensures citizens/residents access to healthcare without payment at the point of service. Apart from free maternal and child health (MCH) for the under 5 children and pregnant mothers upon presentation of evidence of tax payment, there is no prepayment mechanism right now, at the facility. We don’t have anything like that for now.” (IDI-04)

However, the few that had health insurance (prepayment mechanism) were covered up to 90%, implying that they paid only 10% of cost of treatment.

[Table 5] shows the type of ill health reported by respondents and source of treatment in the last one month. Malaria (60.7%) was the most reported followed by typhoid (4.6%) and diarrhea (12%), respectively. In the last one month, more than half of the respondents (54.4%) went to patent medicine dealer (PMD) for treatment, whereas 35.7% of them sought treatment at a public health facility.{Table 5}

[Table 6] presents the logistic regression of the independent variables on the use of prepayment mechanism. It shows that the use of prepayment does not necessarily depend on such variables as gender, marital status, occupation, and number of people in household but rather on age and educational status that were significant at P < 0.05.{Table 6}

 Discussion



This study investigated the level of awareness and use of universal financial risk protection among the population in Enugu state, southeast Nigeria. Findings suggest that over 50% of studied population has some form of information regarding health insurance financial risk protection. This information is mostly obtained from electronic media such as television and radio. The findings also indicate that women are far more informed than men about health insurance as a form of financial risk protection. This is expected because women access health-care services either for self or children more than men. Majority of the respondents were not main income earners (70.9%), despite the fact that a sizeable number had tertiary education (27.2%). However, this is a reflection of the high level of unemployment in the State and among university graduates.[24],[25]

A large number of respondents are not aware of or use any prepayment mechanism despite their appreciable level of education. This goes to show the high level of ignorance especially concerning various government and nongovernmental policies.[26],[27] Moreover, it implies that people/residents mostly use OOP to pay for their health-care service as about 95% used OOP payment to settle their health bills. This is unacceptably high, and a reflection of the high level of catastrophic health expenditure going on in the country.[15],[28] Excessive reliance on the ability to pay through OOP payment reduces health-care consumption, exacerbates the already inequitable access to quality care, and exposes households to the financial risk.[29] OOP payment for health services reduces the amount available for other household consumption, often throwing the families into perpetual borrowing habit, thereby worsening the poverty level of the population.[28]

No wonder, the place of treatment in the last one month for ill health (malaria) was mainly chemist/PMD. The few that had health insurance were covered up to 90%, that is, they bore only 10% of the cost of their treatment. This is in agreement with previous studies in the country.[29],[30] Patronage of PMDs is higher and cheaper as compared with high cost of medical treatment in clinics and hospitals. More so, because many of the patients are poor and ignorant, they prefer this method of health-care delivery.[31],[32] Fewer respondents patronized PHCs (25.4%). The main reason for this is the near total neglect of primary health-care delivery in the country. Many of the PHCs do not have basic medical staff, equipment, and medications.[33],[34] This is unfortunate as this level of health-care delivery would have taken care of those residing in villages and hinterlands. Thus, a wake-up call on government to shift emphasis to PHC as a matter of urgency.

Also, the study showed that use of prepayment mechanisms depends more on age and education than on gender, marital status, occupation, and household status. The higher the age and educational level, the more they are likely to use prepayment mechanism. Better education may mean higher chance of getting better-paid employment and good health-care seeking behavior. On age, older age may imply greater need for health-care services.

The qualitative findings reveal that apart from MCH, there is no prepayment mechanism that ensures citizens access to health care without payment at the point of service. Even the MCH services are not prepayment mechanism but rather a State government arrangement whereby under 5 years and pregnant woman access health-care services without OOP expenses. Our findings showed that although the state adopted formal sector social health insurance program (FSSHIP) as a policy, it has not been operational. This is mainly because of political factors and perhaps lack of commitment by the government. It is necessary to remind the government that healthier population live longer and more productive, thus leading to greater economic prosperity.[35]

In terms of awareness of prepayment mechanisms, it appears that people in the urban areas are increasingly aware as evidenced by increasing number of enrollees among federal employees. However, this is not true of people living in the hinterland/rural area. The finding is in tandem with the study in Ghana, which shows that urban enrolment rates are higher than rural rates as there are more formal sector workers in the urban than in rural areas.[36] In addition, enrolment/membership is compulsory for formal sector workers.[37]

Proponents of UHC have identified OOP/user fees as a barrier to health care, whereas prepayment and risk pooling through social health insurance are found to provide solution.[37],[38] This is because health systems are not just about improving health but also about ensuring that people are protected from financial consequences of illness in having to access medical care.[39]

 Limitation



Most of the respondents were women and were not main income earners in the household. This shows one of the inherent challenges of household questionnaire in developing country because by the time one goes for questionnaire administration, the male head of households (i.e., bread winner/income earner) are already out for daily activities. Subsequent study that will incorporate male head of households may be more enriching.

 Conclusion



OOP still dominates payment mechanism in Enugu state, southeast Nigeria. Although over half of the respondents (55.9%) have heard of prepayment mechanisms, approximately 90% has not used any prepayment mechanism in the State. This calls for policy that will ensure moving away from OOP payment to prepayment mechanism through health system strengthening and awareness creation for the populace.

Acknowledgement

The authors are grateful to all the participants of the study both the interviewees and members of the Health Administration and Management Research Group, University of Nigeria, Enugu Campus.

Financial support and sponsorship

This work was supported by the Tertiary Education Trust Fund (TETFund) Institution-based research grant from the University of Nigeria, TETFund Committee.

Conflicts of interest

There are not conflicts of interest.

References

1Macha J, Harris B, Garshong B, Ataguba JE, Akazili J, Kuwawenaruwa A, et al. Factors influencing the burden of health care financing and the distribution of health care benefits in Ghana, Tanzania and South Africa. Health Policy Plan 2012;27:i46-54.
2McIntyre D, Mills A. Research to support universal coverage reforms in Africa: The SHIELD project. Health Policy Plan 2012;27:i1-3.
3Giedion U, Andrés Alfonso E, Díaz Y. The impact of universal coverage schemes in the developing world: A review of the existing evidence. UNICO Studies Series 25. Washington, DC:The World Bank; 2013.
4WHO. Health systems financing: The path to universal coverage. The world health report. Geneva, Switzerland: World Health Organization;2010.
5WHO. Research for universal health coverage. The world health report. Geneva, Switzerland: World Health Organization; 2013.
6Ataguba J, Akazili J. Health care financing in South Africa: Moving towards universal coverage. CME 2010;28:74-78.
7McIntyre, D. Health service financing for universal coverage in East and Southern Africa. Discussion Paper 95. Harare, Zimbabwe: EQUINET; 2012.
8Averill C. Universal health coverage: Why health insurance schemes are leaving the poor behind. Briefing Paper. Oxford, UK: OXFAM; 2013.
9Arin D, Hongoro C. Scaling up national health insurance in Nigeria: Learning from case studies of India, Colombia, and Thailand. Washington, DC: Futures Group, Health Policy Project; 2013.
10WHO. Everybody's business, strengthening health systems to improve health outcomes: 2007 WHO's framework for action. Geneva, Switzerland: WHO; 2007.
11Xu K, Sun Jeong H, Saksena P, Shin J, Mathauer I, Evans D. Financial risk protection of national health insurance in the Republic of Korea: 1995–2007. World Health Report Background Paper, No. 23: Geneva, Switzerland: World Health Organization; 2010.
12Stuckler D, Feigl A, Basu S, McKee M. The political economy of universal health coverage: Background paper for the global symposium on health systems research. Technical Report. Geneva, Switzerland: WHO; 2010.
13Mohd Rom N, Rahman ZA. Financial protection for the poor in Malaysia: Role of Zakah and Micro-takaful. JKAU: Islamic Econ 2012;25:119-40.
14Shahrawat R, Rao KD. Insured yet vulnerable: Out-of-pocket payments and India's poor. Health Policy Plan 2012;27:213-21.
15Onwujekwe O, Hanson K, Uzochukwu B. Examining inequities in incidence of catastrophic health expenditures on different healthcare services and health facilities in Nigeria. PLoS One 2012;7:e40811.
16National Health Insurance Scheme. Operating guideline; 2012.
17Obikeze E, Onwujekwe O, Uzochukwu B, Chukwuogo O, Uchegbu E, Soludo E, et al. Benefit incidence of National Health Insurance Scheme in Enugu state, Southeast Nigeria. Afr J Health Econ 2013;2:13-30.
18SMoH Enugu. Enugu state strategic health development plan (2017–2021). Enugu: State Ministry of Health; 2017.
19Ezuma N. Enugu state 2012 Joint Annual Review and 2013 Midterm Review of State Strategic Health Development Plan. Enugu: State Ministry of Health; 2013.
20Enugu State. Enugu state: poverty reduction strategy/state economic empowerment development strategy PRS/SEEDS 2004–2009. Ministry of Human Development and Poverty Reduction Enugu State; 2004.
21Okoli CI, Cleary SM. Socioeconomic status and barriers to the use of free antiretroviral treatment for HIV/AIDS in Enugu state, south-eastern Nigeria. Afr J AIDS Res 2011;10:149-55.
22Onwujekwe O, Onoka C, Uguru N, Nnenna T, Uzochukwu B, Eze S, et al. Preferences for benefit packages for community-based health insurance: An exploratory study in Nigeria. BMC Health Serv Res 2010;10:162.
23Kaplan RM, Chambers DA, Glasgow RE. Big data and large sample size: A cautionary note on the potential for bias. Clin Transl Sci 2014;7:342-6.
24Adawo MA, Atan JA. Graduate unemployment in Nigeria: Entrepreneurship and venture capital Nexus. J Econ Sustain Develop 2013;4:75-81.
25Anah CI, Nwosu A, Ezeji N. Graduate unemployment in Nigeria: Implications for national development. Lwati: A J Contem Res 2017;14:25-44.
26Michael TO, Odeyemi MA. Nigeria's population policies: Issues, challenges and prospects. Ibadan J Soc Sci 2017;15:104-115.
27Ibukun C, Komolafe E. Household catastrophic health expenditure: Evidence from Nigeria. Microecon Macroecon 2018;l6:1-8.
28Riman HB, Akpan ES. Healthcare financing and health outcomes in Nigeria: A state level study using multivariate analysis. Int J Human Soc Sci 2012;2:296-309.
29Ilesanmi OS, Adebiyi AO, Fatiregun AA. National Health Insurance Scheme: How protected are households in Oyo state, Nigeria from catastrophic health expenditure? Int J Health Policy Manag 2014;2:175-80.
30Omotosho O, Ichoku IE. Financial protection and universal health coverage in Nigeria. Int Aff Global Strat 2016;51:5-14.
31Adiukwu MU, Okoye KC. Patient factors militating against the law governing prescription only medicines in Nigeria. Niger J Pharm 1992;23:7-11.
32Adiukwu MU. Sales practices of patent medicine sellers in Nigeria. Health Policy Plann 1996;11:202-5.
33Abdukareem SM. Health care problems in Nigeria; 2013. Available from: https://www.academia.edu/8056550/HEALTH_CARE_PROBLEMS_IN_NIGERIA_. [Last accessed on 2018 Apr 20].
34Akplagah W. Health systems in Nigeria: Global health; 2015. Available from: https://www.slideshare.net/wakplagah/health_systems_in_Nigeria.
35The Lancet. Editorial: Investment in health is key to boosting wealth. Lancet. 2019;393:1072.
36Akazili J, Welaga P, Bawah A, Achana FS, Oduro A, Awoonor-Williams JK, et al. Is Ghana's pro-poor health insurance scheme really for the poor? Evidence from northern Ghana. BMC Health Serv Res 2014;14:637.
37Aduo-Adjei K, Owusu R. Insurance and demand for healthcare: Examining the National Health Insurance Scheme in Ghana. J Health Policy Sustain Health 2015;2:183-9.
38Myint P, Sein TT, Cassels A. How can financial risk protection be expanded in Myanmar? Myanmar health systems in transition policy notes #4 series. WPR/2015/DHS/004. Geneva, Switzerland: World Health Organization; 2015.
39Bredenkamp C, Capuno J, Kraft A, Poco L, Quimbo S, Tan CA Jr. Awareness of health insurance benefits in the Philippines: What do people know and how? Health, nutrition and population discussion paper. Washington, DC: The World Bank; 2017.