A qualitative inquiry of access to and quality of primary healthcare in seven communities in East and West Africa (SevenCEWA): perspectives of stakeholders, healthcare providers and users.

BACKGROUND: Universal health coverage is one of the Sustainable Development Goal targets known to improve population health and reduce financial burden. There is little qualitative data on access to and quality of primary healthcare in East and West Africa. The aim of this study was to describe the viewpoints of healthcare users, healthcare providers and other stakeholders on health-seeking behaviour, access to and quality of healthcare in seven communities in East and West Africa. METHODS: A qualitative study was conducted in four communities in Nigeria and one community each in Kenya, Uganda and Tanzania in 2018. Purposive sampling was used to recruit: 155 respondents (mostly healthcare users) for 24 focus group discussions, 25 healthcare users, healthcare providers and stakeholders for in-depth interviews and 11 healthcare providers and stakeholders for key informant interviews. The conceptual framework in this study combined elements of the Health Belief Model, Health Care Utilisation Model, four 'As' of access to care, and pathway model to better understand the a priori themes on access to and quality of primary healthcare as well as health-seeking behaviours of the study respondents. A content analysis of the data was done using MAXQDA 2018 qualitative software to identify these a priori themes and emerging themes. RESULTS: Access to primary healthcare in the seven communities was limited, especially use of health insurance. Quality of care was perceived to be unacceptable in public facilities whereas cost of care was unaffordable in private facilities. Health providers and users as well as stakeholders highlighted shortage of equipment, frequent drug stock-outs and long waiting times as major issues, but had varying opinions on satisfaction with care. Use of herbal medicines and other traditional treatments delayed or deterred seeking modern healthcare in the Nigerian sites. CONCLUSIONS: There was a substantial gap in primary healthcare coverage and quality in the selected communities in rural and urban East and West Africa. Alternative models of healthcare delivery that address social and health inequities, through affordable health insurance, can be used to fill this gap and facilitate achieving universal health coverage.

Willingness and ability to pay for healthcare insurance: A cross-sectional study of Seven Communities in East and West Africa (SevenCEWA).

Willingness and ability to pay for insurance that would cover primary healthcare services has not been evaluated consistently in different African communities. We conducted a cross-sectional community health survey and examined willingness and ability to pay in 3676 adults in seven communities in four countries: Nigeria, Tanzania, Uganda and Kenya. We used an open-ended contingency valuation method to estimate willingness to pay and examined ability to pay indirectly by calculating the ratio of healthcare expenditure to total household income. Slightly more than three quarters (78.8%) of participants were willing to pay for a health insurance scheme, and just a little above half (54.7%) were willing to pay for all household members. Across sites, median amount willing to pay was $2 per person per month. A little above half (57.6%) of households in Nigeria were able to pay the premium. The main predictors of likelihood of being unwilling to pay for the health insurance scheme were increasing age [aOR 0.99 (95% CI 0.98, 1.00)], being female [0.68 (0.51, 0.92], single [0.32 (0.21, 0.49)], unemployment [0.54 (0.34, 0.85)], being enrolled in another health insurance scheme [0.45 (0.28, 0.74)] and spending more on healthcare [1.00 (0.99, 1.00)]. But being widow [2.31 (1.30, 4.10)] and those with primary and secondary education [2.23 (1.54, 3.22)] had increased likelihood of being willing to pay for health insurance scheme. Retired respondents [adjusted mean difference $-3.79 (-7.56, -0.02)], those with primary or secondary education [$-3.05 (-5.42, -0.68)] and those with high healthcare expenditure [$0.02 (0.00, 0.04)] predicted amount willing to pay for health insurance scheme. The willingness to pay for health insurance scheme is high among the seven communities studied in East and West Africa with socio-demography, economic and healthcare cost as main predictive factors.

Hypertension prevalence, awareness, treatment, and control and predicted 10-year CVD risk: a cross-sectional study of seven communities in East and West Africa (SevenCEWA).

BACKGROUND: Few studies have characterized the epidemiology and management of hypertension across several communities with comparable methodologies in sub-Saharan Africa. We assessed prevalence, awareness, treatment, and control of hypertension and predicted 10-year cardiovascular disease risk across seven sites in East and West Africa. METHODS: Between June and August 2018, we conducted household surveys among adults aged 18 years and above in 7 communities in Kenya, Nigeria, Tanzania, and Uganda. Following a standardized protocol, we collected data on socio-demographics, health insurance, and healthcare utilization; and measured blood pressure using digital blood pressure monitors. We estimated the 10-year cardiovascular disease (CVD) risk using a country-specific risk score and fitted hierarchical models to identify determinants of hypertension prevalence, awareness, and treatment. RESULTS: We analyzed data of 3549 participants. The mean age was 39·7 years (SD 15·4), 60·5% of whom were women, 9·6% had ever smoked cigarettes, and 32·7% were overweight/obese. A quarter of the participants (25·4%) had hypertension, more than a half of whom (57·2%) were aware that they had diagnosed hypertension. Among those diagnosed, 50·5% were taking medication, and among those taking medication 47·3% had controlled blood pressure. After adjusting for other determinants, older age was associated with increased hypertension prevalence, awareness, and treatment whereas primary education was associated with lower hypertension prevalence. Health insurance was associated with lower hypertension prevalence and higher chances of treatment. Median predicted 10-yr CVD risk across sites was 4·9% (Interquartile range (IQR), 2·4%, 10·3%) and 13·2% had predicted 10-year CVD risk of 20% or greater while 7·1% had predicted 10-year CVD risk of > 30%. CONCLUSION: In seven communities in east and west Africa, a quarter of participants had hypertension, about 40% were unaware, half of those aware were treated, and half of those treated had controlled blood pressure. The 10-year predicted CVD risk was low across sites. Access to health insurance is needed to improve awareness, treatment, and control of hypertension in sub-Saharan Africa.