A checklist for designing health insurance programmes - a proposed guidelines for Nigerian states.

BACKGROUND: There is widespread and growing interest in designing and implementing social health insurance schemes (SHIS) across many low- and middle-income countries as a means to improve financial protection and achieve universal health coverage. SHIS recently gained traction in Nigeria, but evidence regarding optimal design features of SHIS is sparse and there is lack of a simple and standardised checklist that scheme designers, implementers and researchers could use to assess, guide and inform the design of SHIS. This paper seeks to develop a checklist based on concepts as well as theoretical and empirical evidence that can inform and guide scheme designers and implementers on design options to maximise the effectiveness of the scheme. METHODS: We conducted a review of literature exploring the relevant concepts for the development of a framework and checklist to identify the key factors or variables required to inform the design of SHIS. The checklist details critical considerations/questions to address and options for design. The developed checklist was then used to examine conditions for readiness and appropriateness of SHIS design in two states in Nigeria (Kaduna and Niger). RESULTS: This paper describes the development of a SHIS checklist. The findings also demonstrate that the newly developed checklist, consisting of six design domains, can be used by scheme designers and policy-makers as a simple and effective tool to assess and inform SHIS design features across Nigeria to maximise the chances of the effectiveness of the schemes. CONCLUSION: In conclusion, given that the development of SHIS in the Nigerian states is still in its early stages, applying the SHIS design checklist can serve as a first step to ensuring a feasible and sustainable insurance scheme. The introduction of SHIS, if properly designed and implemented, can be a significant first step towards improving the accessibility, equity and efficiency of healthcare in Nigeria.

A reporting framework for describing and a typology for categorizing and analyzing the designs of health care pay for performance schemes.

BACKGROUND: Pay for Performance (P4P) has increasingly being adopted in different countries as a provider payment mechanism to improve health system performance. Evaluations of pay for performance (P4P) schemes across several countries show significant variation in effectiveness, which may be explained by differences in design. There is however no reliable framework to structure the reporting of the design or a typology to help analyse and interpret results of P4P schemes. This paper reports the development of a reporting framework and a typology of P4P schemes. METHODS: P4P design features were identified from literature and then explored using relevant theories from behavioural and economic science. These design features were then combined with the help of multidimensional tables to produce a reporting framework and a typology which was tested using 74 P4P studies. The inter-rater reliability of the typology was assessed using Fleiss' Kappa. RESULTS: A Healthcare Incentive Scheme Reporting Framework (HISReF) was developed consisting of nine design features. This was collapsed into a typology consisting of 4 items/design features. There was good inter-rater reliability on all the four items on the typology (kappa > 0.7). CONCLUSION: The HISReF provides an important first step towards establishing a common language in which intervention designers can clearly specify the content of P4P designs. Our typology may be used to aid evidence synthesis and interpretation of results of P4P schemes.

Is Nigeria on course to achieve universal health coverage in the context of its epidemiological and financing transition? A knowledge, capacity and policy gap analysis (a qualitative study).

OBJECTIVES: This study aimed to assess Nigeria's preparedness to finance and drive the universal health coverage (UHC) agenda within the context of changing health conditions and resource needs associated with the disease, demographic and funding transitions.Nigeria is undergoing transitions in the healthcare system that include a double burden of infectious and non-communicable diseases, and transition from concessional donor assistance towards domestic financing for health. These transitions will affect Nigeria's attainment of UHC. DESIGN AND SETTING: We conducted a qualitative study, including semistructured interviews with relevant stakeholders at national and subnational levels in Nigeria. Data from the interviews were analysed using thematic analysis. PARTICIPANTS: Our study involved 18 respondents from government ministries, departments, and agencies, development partners, civil society organisations and academia. RESULTS: Capacity gaps identified by respondents included limited knowledge to implement health insurance schemes at subnational levels, poor information/data management to monitor progress towards UHC and limited communication and interagency collaboration between government agencies and ministries. Furthermore, participants in our study expressed those current policies driving major health reforms like the National Health Act (basic healthcare provision fund) appear adequate to support UHC advancement in theory, but policy implementation is a key challenge due to a lack of policy awareness, low government spending on health and poor evidence generation for information to support decisions. CONCLUSION: Our study found major gaps in knowledge and capacity for UHC advancement in the context of Nigeria's demographic, epidemiological and financing transitions. These included poor knowledge of demographic transitions, poor capacity for health insurance implementation at subnational levels, low government spending on health, poor policy implementation and poor communication and collaboration among stakeholders. To address these challenges, collaborative efforts are needed to bridge knowledge gaps and increase policy awareness through targeted knowledge products, improved communication and interagency collaboration.

Optimizing Physician Payment Models to Address Health System Priorities: Perspectives from Specialist Physicians.

OBJECTIVE: Despite well-documented data on the mixed impact of physician payment models, there is limited evidence on how to enhance existing payment model designs. This study examines the approaches to optimizing payment models from the perspective of specialist physicians to better support patient and physician experience and other health system objectives. METHOD: Semi-structured interviews were conducted with 32 specialist physicians across Alberta, Canada. Data from the interviews were analyzed using a framework approach. RESULTS: Respondents emphasized the need to incentivize physicians with the right blend of financial and non-financial incentives, including physician wellness. Respondents also highlighted the need for physician involvement and accountability to optimize the value of physician payment models. CONCLUSION: To optimize physician payment models, it may be useful to include a blend of financial and non-financial incentives with clear accountability measures as this may better align physician practice with health system priorities.

Factors that influence specialist physician preferences for fee-for-service and salary-based payment models: A qualitative study.

Most physicians across the world are paid through fee-for-service. However, there is increased interest in alternative payment models such as salary, capitation, episode-based payment, pay-for-performance, and strategic blends of these models. Such models may be more aligned with broad health policy goals such as fiscal sustainability, delivery of high-quality care, and physician and patient well-being. Despite this, there is limited research on physicians' preferences for different models and a disproportionate focus on differences in income over other issues such as physician autonomy and purpose. Using qualitative interviews with 32 specialist physicians in Alberta, Canada, we examined factors that influence preferences for fee-for-service (FFS) and salary-based payment models. Our findings suggest that a series of factors relating to (1) physician characteristics, (2) payment model characteristics, and (3) professional interests influence preferences. Within these themes, flexibility, autonomy, and compatibility with academic roles were highlighted. To encourage physicians to select a specific payment model, the model must appeal to them in terms of income potential as well as non-monetary values. These findings can support constructive discussions about the merits of different payment models and can assist policy makers in considering the impact of payment reform.

Evidence from the Kaduna State Health Accounts on the pattern of sub-national health spending in Nigeria, 2016.

Health accounts provide accurate estimates of health expenditure, which are important for effective resource allocation and planning in the health sector. In Nigeria, four rounds of health accounts have been conducted at the national level. However, the national estimates do not necessarily reflect realities at the subnational level and may only provide limited information for decision making at that level. This study highlights the pattern of health spending in Kaduna State from the 2016 Health Accounts, with a view to providing more reliable evidence for decision making in the state.Health accounts expenditure surveys were administered to government, donors, non-governmental organizations (NGOs), private health insurance organisations and employers in the health sector for the reference year 2016. Household health expenditure was derived from a household survey administered across a representative sample of 1024 households selected from six local government areas across the three senatorial districts in the state. We estimated disease expenditure by deploying a health provider survey across a sample of 100 health facilities. Analysis was conducted using Microsoft Excel, Stata and the Health Accounts Production Tool.Findings show that current health expenditure (CHE) accounted for only 7% of the total health expenditure in 2016. Out-of-pocket spending among households was about 81% of CHE, compared with a national average of 71.5% of CHE between 2010 and 2014. The health expenditure findings highlight several policy imperatives for the Kaduna State Health System. Primary among these is the heavy dependence on out-of-pocket financing for health, which has negative implications on vulnerable households. A shift to pooled prepaid mechanisms would reduce the financial burden on the most vulnerable households in Kaduna State. In addition, considering the government's current contribution to health expenditure, there is a strong need for increased government prioritisation of the Kaduna State health sector.

Factors influencing willingness and ability to pay for social health insurance in Nigeria.

BACKGROUND: Many low and middle-income countries are increasingly cognisant of the need to offer financial protection to its citizens through pre-payment schemes in order to curb high out of pocket expenditure and catastrophic spending on healthcare. However, there is limited rigorous contextual evidence to make decisions regarding optimal design of such schemes. This study assesses the willingness-to-pay (WTP) for the recently introduced state contributory health insurance scheme (SHIS) in Nigeria. METHODS: The study took place in 6 local government areas in Kaduna state, North-west Nigeria. Data were collected from a household survey using a three-stage cluster sampling approach, with each household having the same probability of being selected. Interviews were conducted with 4000 individuals in 1020 households. Contingent valuation was used to elicit the willing to pay (WTP) for the household using the bidding game technique. The relationship between socioeconomic status and WTP was also examined using logistic regression models. FINDINGS: About 82% of the household heads were willing to pay insurance premiums for their households, which came to an average of 513 Naira (1.68 USD) per month per person. The average amount individuals were willing to pay was lower in rural areas (611 Naira) compared to urban areas (463 Naira). These results were influenced by household size, level of education, occupation and household income. In addition, only 65% of the households had the ability to pay the average premium. CONCLUSION: Socioeconomic factors influence individuals' WTP for contributory health insurance schemes. It is important to create awareness about the benefits of the insurance scheme, especially in rural areas, and in both the formal and informal sectors in Nigeria. WTP information can inform the amount of insurance premiums. However, it is important to consider differences between the WTP and the cost of benefits package to be offered, as the premium amount may need to be subsidized with public financing.

The effectiveness of payment for performance in health care: A meta-analysis and exploration of variation in outcomes.

BACKGROUND: Pay for performance (P4P) incentive schemes are increasingly used world-wide to improve health system performance but results of evaluations vary considerably. A systematic analysis of this variation in the effects of P4P schemes is needed. METHODS: Evaluations of P4P schemes from any country were identified by searching for and updating systematic reviews of P4P schemes in health care in four bibliographic databases. Outcomes using different measures of effect were converted into standardized effect sizes (standardized mean difference, SMD) and each study was categorized as to whether or not it found a positive effect. Subgroup analysis, meta-regression and multilevel logistic regression were used to investigate factors explaining heterogeneity. Random-effects models were used because they take into account heterogeneity likely to be due to differences between studies rather than just chance. Sensitivity analysis was used to test the effect of different assumptions. FINDINGS: 96 primary studies were identified; 37 were included in the meta-analysis and meta-regression and all 96 in the logistic regression. The proportion of observed variation in study results that can be explained by true heterogeneity (I2) was 99.9%. Estimates of effect of P4P schemes were lower in evaluations using randomized controlled trials (SMD=0.08; 95% CI: 0.01-0.15) compared to no controls (0.15; 95% CI: 0.09-0.21), and lower for those measuring outcomes (e.g., smoking cessation) (SMD=0.0; 95% CI: -0.01 to 0.01) compared to process measures (e.g., giving cessation advice) (0.18; 95% CI: 0.06-0.31). Adjusting for other design features and the evaluation method, the odds of showing a positive effect was three times higher for schemes with larger incentives (>5% of salary/usual budget) (OR=3.38; 95% CI: 1.07-10.64). There were non-statistically significant increases in the odds of success if the incentive is paid to individuals (as opposed to groups) (OR=2.0; 95% CI: 0.62-6.56) and if there is a lower perceived risk of not earning the incentive (OR=2.9; 95% CI: 0.78-10.83). Schemes evaluated using less rigorous designs were 24 times more likely to have positive estimates of effect than those using randomized controlled trials (OR=24; 95% CI: 6.3-92.8). INTERPRETATION: Estimates of the effectiveness of incentive schemes on health outcomes are probably inflated due to poorly designed evaluations and a focus on process measures rather than health outcomes. Larger incentives and reducing the perceived risk of non-payment may increase the effect of these schemes on provider behavior.

Pay for performance in Nigeria: the influence of context and implementation on results.

Pay-for-performance (P4P) has recently been introduced in Nigeria to improve quality of health services. Its early results show significant variation between implementation sites. Literature suggests this might be explained by differences in design, context and implementation of the scheme. This study aimed to explore how context and implementation influence P4P in Nigeria. Semi-structured in-depth interviews with 36 health workers explored their views and experiences on how contextual and implementation factors influenced the impact of the P4P scheme. Data were analysed using the framework approach. Four themes captured the views and experiences of participants. Uncertainty of earning the incentive and inadequate infrastructure reduced health worker motivation and performance results; whilst adequate health worker understanding of the scheme and good managerial skills (health facility level) improved motivation and performance. Minimising delays in incentive payments, effective communication and improving the health workers understanding of the P4P scheme are likely to improve the outcomes of pay for performance programmes, independent of their design.

An Assessment of Data Availability, Quality, and Use in Malaria Program Decision Making in Nigeria.

Abstract-In 2014, Nigeria shifted its malaria policy and strategy from control to elimination. Studies show that data-driven decision making is essential to achieving elimination. It is therefore important that policy makers have access to and use good quality and relevant data to inform program decisions. This article presents findings from an assessment of availability, quality, and use of malaria data in three states in Nigeria, namely, Akwa-Ibom, Cross River, and Niger, as part of a larger study on how organizational structure affects outcomes of malaria programs. A literature search to determine the availability and range of malaria data in Nigeria was conducted, followed by 65 key informant interviews to understand how malaria data are used in the study states. It was observed that the District Health Information System (DHIS) was the major source of data used in managing programs; however, the range of malaria indicators in the DHIS is limited, lacking indicators such as active case detection and entomological data, which are important for surveillance and decision making toward malaria elimination. On data quality, routine data from the DHIS were reviewed using the national protocol for data quality assessment. Data quality was found to be suboptimal, with quality scores ranging from 54% to 64% compared to the national target of 80%. DHIS data were reportedly used most often for performance and/or supply chain management. Overall, the study demonstrates gaps in data availability and quality and highlights the need for more data sources and improved quality data to inform decision making toward malaria elimination in Nigeria.

Influence of Organizational Structure and Administrative Processes on the Performance of State-Level Malaria Programs in Nigeria.

Abstract-Studies have found links between organizational structure and performance of public organizations. Considering the wide variation in uptake of malaria interventions and outcomes across Nigeria, this exploratory study examined how differences in administrative location (a dimension of organizational structure), the effectiveness of administrative processes (earmarking and financial control, and communication), leadership (use of data in decision making, state ownership, political will, and resourcefulness), and external influences (donor influence) might explain variations in performance of state malaria programs in Nigeria. We hypothesized that states with malaria program administrative structures closer to state governors will have greater access to resources, greater political support, and greater administrative flexibility and will therefore perform better. To assess these relationships, we conducted semistructured interviews across three states with different program administrative locations: Akwa-Ibom, Cross River, and Niger. Sixty-five participants were identified through a snowballing approach. Data were analyzed using a thematic framework. State program performance was assessed across three malaria service delivery domains (prevention, diagnosis, and treatment) using indicators from Nigeria Demographic and Health Surveys conducted in 2008 and 2013. Cross River State was best performing based on 2013 prevention data (usage of insecticide-treated bednets), and Niger State ranked highest in diagnosis and treatment and showed the greatest improvement between 2008 and 2013. We found that organizational structure (administrative location) did not appear to be determinative of performance but rather that the effectiveness of administrative processes (earmarking and financial control), strong leadership (assertion of state ownership and resourcefulness of leaders in overcoming bottlenecks), and donor influences differed across the three assessed states and may explain the observed varying outcomes.