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.

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.

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.

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.

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.

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.