Environmental, economic and socio-cultural risk factors of recurrent seasonal epidemics of cerebrospinal meningitis in Kebbi state, northwestern Nigeria: a qualitative approach.

BACKGROUND: Kebbi State remains the epicentre of the seasonal epidemic meningitis in northwestern Nigeria despite interventions. In this setting, no previous study has been conducted to understand the risk factors of the recurrent meningitis epidemics using qualitative approach. Consequently, this study intends to explore and better understand the environmental, economic and socio-cultural factors of recurrent seasonal epidemic meninigitis using a qualitative approach. METHODS: We conducted in-depth interview (40 IDIs) and focus group discussions (6 FGDs) in two local government areas (LGAs) in Kebbi State, Northwestern Nigeria to understand the environmental, economic and socio-cultural factors of recurrent meningitis outbreaks. Routine surveillance data were used to guide the selection of settlements, wards and local government areas based on the frequency of re-occurrences and magnitude of the outbreaks. RESULTS: The discussions revealed certain elements capable of potentiating the recurrence of seasonal meningitis epidemics. These are environmental issues, such as poorly-designed built environment, crowded sleeping and poorly ventilated rooms, dry and dusty weather condition. Other elements were economic challenges, such as poor household living conditions, neighbourhood deprivation, and socio-cultural elements, such as poor healthcare seeking behaviour, social mixing patterns, inadequate vaccination and vaccine hesitancy. CONCLUSION: As suggested by participants, there are potential environmental, socio-cultural and economic factors in the study area that might have been driving recurrent epidemics of cerebrospinal meningitis. In a bid to addressing this perennial challenge, governments at various levels supported by health development partners such as the World Health Organisation (WHO), United Nation Habitat, and United National Development Programme can use the findings of this study to design policies and programmes targeting these factors towards complementing other preventive and control strategies.

Patients' satisfaction with HIV and AIDS care in Anambra State, Nigeria.

INTRODUCTION: HIV and AIDS care requires frequent visits to the hospital. Patient satisfaction with care services during hospital visits is important in considering quality and outcome of care. Increasing number of patients needing treatment led to the decentralization of care to lower level hospitals without documented patient perception on the quality of services. The study determined and compared patient satisfaction with HIV and AIDS care services in public and private hospitals and identified the factors that influence it. METHOD: This was a cross-sectional comparative study of patients receiving antiretroviral treatment in public and private hospitals in Anambra State. The sampling frame for the hospitals consisted of all registered public and private hospitals that have rendered antiretroviral services for at least one year. There were three public urban, nine public rural, eleven private urban and ten private rural hospitals that met the criteria. One hospital was selected by simple random sampling (balloting) from each group. Out of a total of 6334 eligible patients (had received ART for at least 12 months), 1270 were recruited by simple random sampling from the hospitals proportionate to size of patient in each hospital. Adapted, validated and pretested Patient Satisfaction Questionnaire (PSQ18) was interviewer-administered on consenting patients as an exit interview. A Chi-square test and logistic regression analysis were conducted at 5% level of significance. RESULT: There were 635 participants each in public and private hospitals. Of the 408 patients who had primary education or less, 265(65.0%) accessed care in public hospitals compared to 143(35.0%) who accessed care in private hospital (p<0.001). Similarly, of the 851 patients who were currently married, 371 (43.6%) accessed their care in public compared to 480 (56.4%) who accessed care in private (p<0.001). The proportion of participants who were satisfied were more in public hospitals (71.5%) compared to private hospitals (41.4%). The difference in proportion was statistically significant (χ2 = 116.85, p <0.001). Good retention in care [AOR: 2.3, 95%CI: 1.5-3.5] was the only predictor of satisfaction in public hospitals while primary education [adjusted odds ratio (AOR); 2.3, 95%CI: 1.5-3.4], residing in rural area [AOR: 2.0, 95%CI: 1.4-2.9], and once-daily dosing [AOR: 3.2, 95%CI: 2.1-4.8] were independent predictors of patient' satisfaction among private hospital respondents. CONCLUSION: Satisfaction was higher among patients attending public hospitals. Patient's satisfaction was strongly associated with retention in care among patients in public hospitals. However, in private hospitals, it was influenced by the patient's level of education, place of residence, and antiretroviral medication dosing frequency.

Examining the Financial Feasibility of Using a New Special Health Fund to Provide Universal Coverage for a Basic Maternal and Child Health Benefit Package in Nigeria.

Background: A special health fund was established in Nigeria in 2014 and is known as the Basic Health Care Provision Fund (BHCPF). The fund is equivalent to at least 1% of the Consolidated Revenue of the Federation. The BHCPF will provide additional revenue to fund primary healthcare services and help Nigeria to achieve universal health coverage (UHC). This fund is to be matched with counterpart funds from states and local government areas (LGAs), and is expected to provide at least a basic benefit health package that will cover maternal and child health (MCH) services for pregnant women and under-five children. Objective: To determine the financial feasibility of using the BHCPF to provide a minimum benefit package to cover all pregnant women and under-five children in Nigeria. Methods: The study focused on three states in Nigeria: Imo, Kaduna, and Niger. The feasibility analysis was performed using 3 scenarios but the main analysis was Scenario 1, which was based on the funding of drugs and consumables only. All the costs and revenues were in 2015 levels. The standard costs of a minimum benefit package for the different states were multiplied by the number of target beneficiaries to determine the amount required for the year. Financial feasibility is determined by the excess or otherwise of revenue over costs. Findings: It was found that in the best case funding scenario of using 95% of the CRF with 25% counterpart funding from states and LGAs, the entire available funds were not adequate to cover the benefit package for all the pregnant women and under-five children in the three states. The funds were also inadequate to cover the target beneficiaries that live below the poverty line in two of the states. Conclusion: The BHCPF is a good step toward providing essential MCH services, but the current level of funding will not assure UHC for all the target beneficiaries. However, the available funds should be used immediately to target priority mothers and children such as vulnerable groups, whilst sourcing for additional funds to ensure universal coverage of MCH services.

Disparities in tobacco use by adolescents in southeast, Nigeria using Global Youth Tobacco Survey (GYTS) approach.

BACKGROUND: Tobacco use during adolescence is a substantial problem and adolescents are at higher risk of addiction and prolonged use. To reduce the burden of tobacco-related morbidity and mortality, monitoring of adolescent tobacco use is imperative. We aimed to determine the prevalence of tobacco use among adolescents in urban and rural secondary schools in Enugu State, southeast Nigeria. METHODS: A cross-sectional study of 4332 adolescents in 8th to 10th grades in 25 urban and 24 rural secondary schools in Enugu, Nigeria was done using Global Youth Tobacco Survey (GYTS) methodology. Students were asked about previous and current tobacco use, smoking cessation, and susceptibility to smoking initiation among non-smokers. Geographical, age and sex prevalence differences were examined. Analyses were performed for all adolescents (10-19 years) and for a subset of students, 13-15 years of age for comparison with previous GYTS surveys. All analyses were weighted to account for the complex survey design and for differential non-response at school, class and student levels. RESULTS: About 28.9% of students reported ever smoking cigarettes; 19.4% reported current tobacco use among all adolescents (13.3, 5.8 and 7.8% for cigarettes, other smoked tobacco, and smokeless tobacco, respectively) while 18.6% reported current tobacco use among 13-15 year olds (12.6, 5.2 and 7.5% for cigarettes, other smoked tobacco and smokeless tobacco respectively). Prevalence of all types of tobacco use was higher in rural schools (vs. urban schools), and among boys (vs. girls). Susceptibility to smoking initiation among non-smokers was 9.3% (95% CI: 8.1-10.7) among all adolescents, and 9% (95% CI: 7.6-10.7) among 13-15 year olds. About 88.1% of all adolescent smokers desired to quit and 57.9% of them had never received help to quit smoking. CONCLUSIONS: Nearly one in every five school-going adolescents currently uses at least one type of tobacco in Enugu State, southeast Nigeria. Prevalence of tobacco use is higher in rural schools and among boys in this setting. Most adolescent current smokers desire to quit and need smoking cessation support.

Growth of health maintenance organisations in Nigeria and the potential for a role in promoting universal coverage efforts.

There has been growing interest in the potential for private health insurance (PHI) and private organisations to contribute to universal health coverage (UHC). Yet evidence from low and middle income countries remains very thin. This paper examines the evolution of health maintenance organisations (HMOs) in Nigeria, the nature of the PHI plans and social health insurance (SHI) programmes and their performance, and the implications of their business practices for providing PHI and UHC-related SHI programmes. An embedded case study design was used with multiple subunits of analysis (individual HMOs and the HMO industry) and mixed (qualitative and quantitative) methods, and the study was guided by the structure-conduct-performance paradigm that has its roots in the neo-classical theory of the firm. Quantitative data collection and 35 in-depth interviews were carried out between October 2012 to July 2013. Although HMOs first emerged in Nigeria to supply PHI, their expansion was driven by their role as purchasers in the government's national health insurance scheme that finances SHI programmes, and facilitated by a weak accreditation system. HMOs' characteristics distinguish the market they operate in as monopolistically competitive, and HMOs as multiproduct firms operating multiple risk pools through parallel administrative systems. The considerable product differentiation and consequent risk selection by private insurers promote inefficiencies. Where HMOs and similar private organisations play roles in health financing systems, effective regulatory institutions and mandates must be established to guide their behaviours towards attainment of public health goals and to identify and control undesirable business practices. Lessons are drawn for policy makers and programme implementers especially in those low and middle-income countries considering the use of private organisations in their health financing systems.

Building Sustainable Local Capacity for Global Health Research in West Africa.

BACKGROUND: Global health research in resource-limited countries has been largely sponsored and led by foreign institutions. Thus, these countries' training capacity and productivity in global health research is limited. Local participation at all levels of global health knowledge generation promotes equitable access to evidence-based solutions. Additionally, leadership inclusive of competent local professionals promotes best outcomes for local contextualization and implementation of successful global health solutions. Among the sub-Saharan African regions, West Africa in particular lags in research infrastructure, productivity, and impact in global health research. OBJECTIVE: In this paper, experts discuss strategies for scaling up West Africa's participation in global health evidence generation using examples from Ghana and Nigeria. METHODS: We conducted an online and professional network search to identify grants awarded for global health research and research education in Ghana and Nigeria. Principal investigators, global health educators, and representatives of funding institutions were invited to add their knowledge and expertise with regard to strengthening research capacity in West Africa. FINDINGS: While there has been some progress in obtaining foreign funding, foreign institutions still dominate local research. Local research funding opportunities in the 2 countries were found to be insufficient, disjointed, poorly sustained, and inadequately publicized, indicating weak infrastructure. As a result, research training programs produce graduates who ultimately fail to launch independent investigator careers because of lack of mentoring and poor infrastructural support. CONCLUSIONS: Research funding and training opportunities in Ghana and Nigeria remain inadequate. RECOMMENDATIONS: We recommend systems-level changes in mentoring, collaboration, and funding to drive the global health research agenda in these countries. Additionally, research training programs should be evaluated not only by numbers of individuals graduated but also by numbers of independent investigators and grants funded. Through equitable collaborations, infrastructure, and mentoring, West Africa can match the rest of Africa in impactful global health research.

Towards universal coverage: a policy analysis of the development of the National Health Insurance Scheme in Nigeria.

This article examines why and how a national health insurance (NHI) proposal targeting universal health coverage (UHC) in Nigeria developed over time. The study involved document reviews, in-depth interviews, a further review of preliminary analysis by relevant actors and use of a stakeholder analysis approach. The need for strategies to improve healthcare funding during the economic recession of the 1980s stimulated the proposal. The inclusion of Health Maintenance Organizations (HMOs) as financing organizations for national health insurance at the expense of sub-national (state) government mechanisms increased credibility of policy implementation but resulted in loss of support from states. The most successful period of the policy process occurred when a new minister of health (strongly supported by the president that displayed interest in UHC) provided leadership through the Federal Ministry of Health (FMOH), and effectively managed stakeholders' interests and galvanized their support to advance the policy. Later, the National Health Insurance Scheme (the federal government's implementing/regulatory agency) assumed this leadership role but has been unable to extend coverage in a significant way. Nigeria's experience shows that where political leaders are interested in a UHC-related proposal, the strong political leadership they provide considerably enhances the pace of the policy process. However, public officials should carefully guide policymaking processes that involve private sector actors, to ensure that strategies that compromise the chance of achieving UHC are not introduced. In contexts where authority is shared between federal and state governments, securing federal level commitment does not guarantee that a national health insurance proposal has become a 'national' proposal. States need to be provided with an active role in the process and governance structure. Finally, the article underscores the utility of retrospective stakeholder analysis in understanding the reasons for changes in stakeholder positions over time, which is useful to guide future policy processes.

Promoting universal financial protection: constraints and enabling factors in scaling-up coverage with social health insurance in Nigeria.

BACKGROUND: The National Health Insurance Scheme (NHIS) in Nigeria was launched in 2005 as part of efforts by the federal government to achieve universal coverage using financial risk protection mechanisms. However, only 4% of the population, and mainly federal government employees, are currently covered by health insurance and this is primarily through the Formal Sector Social Health Insurance Programme (FSSHIP) of the NHIS. This study aimed to understand why different state (sub-national) governments decided whether or not to adopt the FSSHIP for their employees. METHODS: This study used a comparative case study approach. Data were collected through document reviews and 48 in-depth interviews with policy makers, programme managers, health providers, and civil servant leaders. RESULTS: Although the programme's benefits seemed acceptable to state policy makers and the intended beneficiaries (employees), the feasibility of employer contributions, concerns about transparency in the NHIS and the role of states in the FSSHIP, the roles of policy champions such as state governors and resistance by employees to making contributions, all influenced the decision of state governments on adoption. Overall, the power of state governments over state-level health reforms, attributed to the prevailing system of government that allows states to deliberate on certain national-level policies, enhanced by the NHIS legislation that made adoption voluntary, enabled states to adopt or not to adopt the program. CONCLUSIONS: The study demonstrates and supports observations that even when the content of a programme is generally acceptable, context, actor roles, and the wider implications of programme design on actor interests can explain decision on policy adoption. Policy implementers involved in scaling-up the NHIS programme need to consider the prevailing contextual factors, and effectively engage policy champions to overcome known challenges in order to encourage adoption by sub-national governments. Policy makers and implementers in countries scaling-up health insurance coverage should, early enough, develop strategies to overcome political challenges inherent in the path to scaling-up, to avoid delay or stunting of the process. They should also consider the potential pitfalls of reforms that first focus on civil servants, especially when the use of public funds potentially compromises coverage for other citizens.

Viewing health expenditures, payment and coping mechanisms with an equity lens in Nigeria.

BACKGROUND: This paper examines socio-economic and geographic differences in payment and payment coping mechanisms for health services in southeast Nigeria. It shows the extent to which the poor and rural dwellers disproportionally bear the burden of health care costs and offers policy recommendations for improvements. METHODS: Questionnaires were used to collect data from 3071 randomly selected households in six communities in southeast Nigeria using a four week recall. The sample was divided into quintiles (Q1-Q5) using a socio-economic status (SES) index as well as into geographic groups (rural, peri-urban and urban). Tabulations and logistic regression were used to determine the relationships between payment and payment coping mechanisms and key independent variables. Q1/Q5 and rural/urban ratios were the measures of equity. RESULTS: Most of the respondents used out-of-pocket spending (OOPS) and own money to pay for healthcare. There was statistically significant geographic differences in the use of own money to pay for health services indicating more use among rural dwellers. Logistic regression showed statistically significant geographic differences in the use of both OOPS and own money when controlling for the effects of potential cofounders. CONCLUSIONS: This study shows statistically significant geographic differences in the use of OOPS and own money to pay for health services. Though the SES differences were not statistically significant, they showed high equity ratios indicating more use among poor and rural dwellers. The high expenditure incurred on drugs alone highlights the need for expediting pro-poor interventions like exemptions and waivers aimed at improving access to health care for the vulnerable poor and rural dwellers.

Sub-optimal delivery of intermittent preventive treatment for malaria in pregnancy in Nigeria: influence of provider factors.

BACKGROUND: The level of access to intermittent preventive treatment for malaria in pregnancy (IPTp) in Nigeria is still low despite relatively high antenatal care coverage in the study area. This paper presents information on provider factors that affect the delivery of IPTp in Nigeria. METHODS: Data were collected from heads of maternal health units of 28 public and six private health facilities offering antenatal care (ANC) services in two districts in Enugu State, south-east Nigeria. Provider knowledge of guidelines for IPTp was assessed with regard to four components: the drug used for IPTp, time of first dose administration, of second dose administration, and the strategy for sulphadoxine-pyrimethamine (SP) administration (directly observed treatment, DOT). Provider practices regarding IPTp and facility-related factors that may explain observations such as availability of SP and water were also examined. RESULTS: Only five (14.7%) of all 34 providers had correct knowledge of all four recommendations for provision of IPTp. None of them was a private provider. DOT strategy was practiced in only one and six private and public providers respectively. Overall, 22 providers supplied women with SP in the facility and women were allowed to take it at home. The most common reason for doing so amongst public providers was that women were required to come for antenatal care on empty stomachs to enhance the validity of manual fundal height estimation. Two private providers did not think it was necessary to use the DOT strategy because they assumed that women would take their drugs at home. Availability of SP and water in the facility, and concerns about side effects were not considered impediments to delivery of IPTp. CONCLUSION: There was low level of knowledge of the guidelines for implementation of IPTp by all providers, especially those in the private sector. This had negative effects such as non-practice of DOT strategy by most of the providers, which can lead to low levels of adherence to IPTp and ineffectiveness of IPTp. Capacity development and regular supportive supervisory visits by programme managers could help improve the provision of IPTp.

Constraints to universal coverage: inequities in health service use and expenditures for different health conditions and providers.

BACKGROUND: There is need for new information about the socio-economic and geographic differences in health seeking and expenditures on many health conditions, so to help to design interventions that will reduce inequity in utilisation of healthcare services and ensure universal coverage. OBJECTIVES: The paper contributes additional knowledge about health seeking and economic burden of different health conditions. It also shows the level of healthcare payments in public and private sector and their distribution across socioeconomic and geographic population groups. METHODS: A questionnaire was used to collect data from randomly selected householders from 4,873 households (2,483 urban and 2,390 rural) in southeast Nigeria. Data was collected on: health problems that people had and sought care for; type of care sought, outpatient department (OPD) visits and inpatient department (IPD) stays; providers visited; expenditures; and preferences for improving access to care. Data was disaggregated by socio-economic status (SES) and geographic location (urban versus rural) of the households. RESULTS: Malaria and hypertension were the major communicable and non-communicable diseases respectively that required OPD and IPD. Patent medicine dealers (PMDs) were the most commonly used providers (41.1%), followed by private hospitals (19.7%) and pharmacies (16.4%). The rural dwellers and poorer SES groups mostly used low-level and informal providers. The average monthly treatment expenditure in urban area was 2444 Naira (US$20.4) and 2267 Naira (US$18.9) in the rural area. Higher SES groups and urbanites incurred higher health expenditures. People that needed healthcare services did not seek care mostly because the health condition was not serious enough or they could not afford the cost of services. CONCLUSION: There were inequities in use of the different providers, and also in expenditures on treatment. Reforms should aim to decrease barriers to access to public and formal health services and also identify constraints which impede the equitable distribution and access of public health services for the general population especially for poor people and rural dwellers.

Examining catastrophic health expenditures at variable thresholds using household consumption expenditure diaries.

OBJECTIVE: Using uniform thresholds and a set of variable threshold levels, this study examined the incidence of catastrophe amongst households of different socio-economic status (SES) quintiles. METHODS: A household diary was used to collect illness and household consumption expenditure data from 1128 households over 1 month. Catastrophic health expenditure was examined based on uniform threshold levels of non-food expenditure and a novel set of variable thresholds in which the levels for various SES groups were weighted by the ratio of household expenditure on food. RESULTS: A total of 167 households (14.8%) experienced catastrophe at a non-food expenditure threshold of 40%, with 22.6% and 7.6% of the poorest and richest household quintiles experiencing catastrophe. For the first set of variable scenarios, the thresholds for the poorest and richest household quintiles were 5% and 29.6% and levels of catastrophe were 44.7% and 12.0%, respectively, while the overall level was 36.5%. In the second scenario, the thresholds were 6.8% and 40%, and the levels of catastrophe were 42.5% and 7.6%, respectively, while the overall level was 32.0%. CONCLUSIONS: High levels of catastrophic expenditure exist in Nigeria. Use of variable thresholds to measure catastrophe led to higher overall and disaggregated levels of catastrophe. Such a measure is argued to be more appropriate for the examination of catastrophe.

Preferences for benefit packages for community-based health insurance: an exploratory study in Nigeria.

BACKGROUND: It is important that community-based health insurance (CBHI) schemes are designed in such a way as to ensure the relevance of the benefit packages to potential clients. Hence, this paper provides an understanding of the preferred benefit packages by different economic status groups as well as urban and rural dwellers for CBHI in Southeast Nigeria. METHODS: The study took place in rural, urban and semi-urban communities of south-east Nigeria. A questionnaire was used to collect information from 3070 randomly picked household heads. Focus group discussions were used to collect qualitative data. Data was examined for links between preferences for benefit packages with SES and geographic residence of the respondents. RESULTS: Respondents in the rural areas and in the lower SES preferred a comprehensive benefit package which includes all inpatient, outpatient and emergencies services, while those in urban areas as well as those in the higher SES group showed a preference for benefit packages which will cover only basic disease control interventions. CONCLUSION: Equity concerns in preferences for services to be offered by the CBHI scheme should be addressed for CBHI to succeed in different contexts.

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.

Willingness to pay for community-based health insurance in Nigeria: do economic status and place of residence matter?

OBJECTIVE: We examine socio-economic status (SES) and geographic differences in willingness of respondents to pay for community-based health insurance (CBHI). METHODS: The study took place in Anambra and Enugu states, south-east Nigeria. It involved a rural, an urban and a semi-urban community in each of the two states. A pre-tested interviewer-administered questionnaire was used to collect information from a total of 3070 households selected by simple random sampling. Contingent valuation was used to elicit willingness to pay (WTP) using the bidding game format. Data were examined for correlation between SES and geographic locations with WTP. Log ordinary least squares (OLS) was used to examine the construct validity of elicited WTP. RESULTS: Generally, less than 40% of the respondents were willing to pay for CBHI membership for themselves or other household members. The proportions of people who were willing to pay were much lower in the rural communities, at less than 7%. The average that respondents were willing to pay as a monthly premium for themselves ranged from 250 Naira (US$1.7) in a rural community to 343 Naira (US$2.9) in an urban community. The higher the SES group, the higher the stated WTP amount. Similarly, the urbanites stated higher WTP compared with peri-urban and rural dwellers. Males and people with more education stated higher WTP values than females and those with less education. Log OLS also showed that previously paying out-of-pocket for health care was negatively related to WTP. Previously paying for health care using any health insurance mechanism was positively related to WTP. CONCLUSION: Economic status and place of residence amongst other factors matter in peoples' WTP for CBHI membership. Consumer awareness has to be created about the benefits of CBHI, especially in rural areas, and the amount to be paid has to be augmented with other means of financing (e.g. government and/or donor subsidies) to ensure success and sustainability of CBHI schemes.

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.

Examining catastrophic costs and benefit incidence of subsidized antiretroviral treatment (ART) programme in south-east Nigeria.

OBJECTIVES: To examine the extent to which costs of subsidized antiretrovirals treatment (ART) programmes are catastrophic and the benefit incidence that accrues to different population groups. METHODS: Data on expenditures to patients for receiving treatment from a government subsidized ART clinic was collected using a questionnaire. The patient costs excluded time and other indirect costs. Catastrophic cost was determined as the percentage of total expenditure on ART treatment as a proportion of household non-food expenditures on essential items. RESULTS: On average, patients spent 990 Naira (US$ 8.3) on antiretroviral (ARV) drugs per month. They also spent an average of $8.2 on other drugs per month. However, people that bought ARV drugs from elsewhere other than the ART clinic spent an average of $88.8 per month. Patients spent an average of $95.1 on laboratory tests per month. Subsidized ARV drugs depleted 9.8% of total household expenditure, other drugs (e.g. for opportunistic infections) depleted 9.7%, ARV drugs from elsewhere depleted 105%, investigations depleted 112.9% and total expenditure depleted 243.2%. The level of catastrophe was generally more with females, rural dwellers and most poor patients. Females and urbanites had more benefit incidence than males and rural dwellers. CONCLUSION: Subsidized ART programme lowers the cost of ARV drugs but other major costs are still incurred, which make the overall cost of accessing and consuming ART treatment to be excessive and catastrophic. The costs of laboratory tests and other drugs should be subsidized and there should also be targeting of ART programme to ensure that more rural dwellers and the most-poor people have increased benefit incidence.