Examining community-based health insurance (CBHI) financial risk protection in southeast Nigeria

1. Examining community-based health insurance (CBHI) financial risk protection in southeast Nigeria byChijiokeOkoli, ObinnaOnwujekwe, Benjamin Uzochukwu & Eric ObikezeHealth Policy Research GroupCollege of MedicineUniversity of Nigeria, Enugu Campus

2. Background Objective of study Methods Results Discussion and conclusion Outline

3. Background • Community- based health Insurance (CBHI) scheme is a non-profit type of health insurance used by poor people and those in the informal sector to protect themselves against the financial risk of illness. • CBHI is based on collective pooling of health risks • members pay small premiums on a regular basis to offset the risk of needing to pay large health care fees upon falling sick. • Membership in the scheme is voluntary

4. Background contd • In Anambra State, CBHI scheme was initiated in 2003 to restrain the dwindling health care delivery that arose due to: • Budget constraint • Health workers industrial action that lasted for one year and • The consequent closure of all public health facilities • However, membership to scheme in the state is by individuals/households and a minimum of 500 persons were required to form a user group. • Members pay a N100 ($0.8) flat rate monthly, or yearly or in convenient instalments.

5. Background contd • The scheme is managed by 3 persons employed by the Community Health Committee (CHC). • The CHC is made up of : • the traditional ruler • the town union president • the town woman leader • representative of the Ministry of Health • representative of the Local Government Area • one male and one female from each of the community.

6. Objective of study • To determine CBHI financial risk protection in two communities with varying success levels in implementing the scheme.

7. Methods: study area • The study was undertaken in Anambra State, southeast Nigeria. • population of about 4.1 million people. • the state consists of 21 local government areas and 3 senatorial zone. • Prior to the study, CBHI was established in 10 communities namely: • IfiteOgwari, Ugbene and Achala in Anambra north senatorial zone; • Abagana, Alor, Neni and Awka in Anambra central senatorial zone and • Igbokwu, Okija and Mbosi in Anambra south senatorial zone. • Apart from Awka, the state capital, all other communities are rural communities. • Each community has a health centre that serves between 4-7 villages

8. Methods: Study design • The study was cross sectional - quantitative. • Out of the 10 pilot communities in 9 rural and 1 urban LGAs, 2 communities from 2 rural LGAs were selected for the study. • The 2 rural LGAs were selected because most of the LGAs where the scheme is piloted are rural and mainly inhabited by people in the informal sector. • One successful site (Igboukwu) and one not successful site (Neni) were purposively chosen. • CBHI scheme success was determined by enrolment data in the facilities being used as well as views of the state managerial team.

9. Sampling and sample size • Quantitative and WTP data were collected using a pre-tested interviewer-administered questionnaire. • The contingent valuation method (CVM) was used to elicit WTP using the bidding game and structured haggling question formats. • Questionnaire was administered to 1000 households/respondents (i.e 500 per community) • Households were selected by simple random sampling from a sample frame of primary health care house numbering system. • Adequate sample size was determined, using a power of 80%, 95% confidence level and utilization rate of public health facilities of 20%. • The heads of households or their representatives (if the household head was absent) were interviewed.

10. Data collection and analysis • Demographic and socio-economic characteristics data as well as willingness to renew registration. • SES information on asset ownership and household weekly food expenditure were also collected. • Principal components analysis method was used to generate SES index in order to examine whether there were systematic differences in enrolment into the scheme. • the study populations were classified into four quartiles (least poor, poor, very poor and poorest) • The Kruskal-Wallis statistic was used to determine whether means of quartiles were significantly different.

11. Results SOCIO-ECONOMIC CHARACTERISTICS • A total of 455 and 516 questionnaires for Igboukwu and Neni respectively were available for analysis. • Majority of the respondents were females and wives or female household heads. • The highest level of education and occupation of enrollees in the scheme in both communities were primary education and petty trading. • 36.5% in Igboukwu and 32.8% in Neni had primary education while 50.3% in Igboukwu and 61.4% in Neni were petty traders.

12. Result contd • Mean per capita household weekly food expenditure was N726.3 ($5.8) in Igboukwu and N508.1 ($4.1) for Neni.

13. Enrolment with CBHI

14. Reasons for registering

15. Result contd • Most respondents who registered did so because they perceived that the scheme offered financial risk protection • Availability of good quality drug was the next most common reason for registering in both communities. • Mean cost of registration was highest amongst the most poor in Igboukwu (N130.2, SD=128.3) and highest amongst the poor group in Neni

16. Willingness to renew

17. Discussion and conclusion • Coverage was low in both communities but more especially in the community the scheme was less successful. • Although the average premiums were small, the contributions were regressive and unaffordable to the very poor. • For sustainability and financial viability of CBHI, efforts need to be made to increase the number of enrollees, so as to increase the pool of funds and risk sharing. • CBHI premiums should be supplemented by subsidies from government and donor funding in order to ensure equitable financial risk protection.

18. Merci!

19. Acknowledgment • Consortium for Research on Equitable Health Systems (CREHS) • Health Policy Research Group, Enugu, Nigeria