The prominent role of informal medicine vendors despite health insurance: a weekly diaries study in rural Nigeria.

In sub-Saharan Africa, accessibility to affordable quality care is often poor and health expenditures are mostly paid out of pocket. Health insurance, protecting individuals from out-of-pocket health expenses, has been put forward as a means of enhancing universal health coverage. We explored the utilization of different types of healthcare providers and the factors associated with provider choice by insurance status in rural Nigeria. We analysed year-long weekly health diaries on illnesses and injuries (health episodes) for a sample of 920 individuals with access to a private subsidized health insurance programme. The weekly diaries capture not only catastrophic events but also less severe events that are likely underreported in surveys with longer recall periods. Individuals had insurance coverage during 34% of the 1761 reported health episodes, and they consulted a healthcare provider in 90% of the episodes. Multivariable multinomial logistic regression analyses showed that insurance coverage was associated with significantly higher utilization of formal health care: individuals consulted upgraded insurance programme facilities in 20% of insured episodes compared with 3% of uninsured episodes. Nonetheless, regardless of insurance status, most consultations involved an informal provider visit, with informal providers encompassing 73 and 78% of all consultations among insured and uninsured episodes, respectively, and individuals spending 54% of total annual out-of-pocket health expenditures at such providers. Given the high frequency at which individuals consult informal providers, their position within both the primary healthcare system and health insurance schemes should be reconsidered to reach universal health coverage.

Impact of the community healthcare plan and the free maternity services programme on maternal and child healthcare utilisation in rural Kenya: a dairy farmer population-based study.

BACKGROUND: Access to and utilisation of quality maternal and child healthcare services is generally recognized as the best way to reduce maternal and child mortality. OBJECTIVES: We evaluated whether the introduction of a voluntary family health insurance programme, combined with quality improvement of healthcare facilities [The Community Health Plan (TCHP)], and the introduction of free access to delivery services in all public facilities [Free Maternity Services programme (FMS)] increased antenatal care utilisation and use of facility deliveries among pregnant women in rural Kenya. METHODS: TCHP was introduced in 2011, whilst the FMS programme was launched in 2013. To measure the impact of TCHP, percentage points (PP) changes in antenatal care utilisation and facility deliveries from the pre-TCHP to the post-TCHP period between the TCHP programme area and a control area were compared in multivariable difference-in-differences analysis. To measure the impact of the FMS programme, PP changes in antenatal care utilisation and facility deliveries from the pre-FMS to the post-FMS period in the pooled TCHP programme and control areas was assessed in multivariable logistic regression analysis. Data was collected through household surveys in 2011 and 2104. Households (n=549) were randomly selected from the member lists of 2 dairy companies, and all full-term pregnancies in the 3.5 years preceding the baseline and follow-up survey among women aged 15-49 at the time of pregnancy were eligible for this study (n=295). RESULTS: Because only 4.1% of eligible women were insured through TCHP during pregnancy, any increase in utilisation attributable to the TCHP programme could only have come about as a result of the quality improvements in TCHP facilities. Antenatal care utilisation significantly increased after TCHP was introduced (14.4 PP; 95% CI: 4.5-24.3; P=0.004), whereas no effect was observed of the programme on facility deliveries (8.8 PP; 95% CI: -14.1 to +31.7; P=0.450). Facility deliveries significantly increased after the introduction of the FMS programme (27.9 PP; 95% CI: 11.8-44.1; P=0.001), but antenatal care utilisation did not change significantly (4.0 PP; 95% CI: -0.6 to +8.5; P=0.088). CONCLUSION: Access to the FMS programme increased facility deliveries substantially and may contribute to improved maternal and new-born health and survival if the quality of delivery services is sustained or further improved. Despite low up-take, TCHP had a positive effect on antenatal care utilisation among uninsured women by improving the quality of existing healthcare facilities. An alignment of the two programmes could potentially lead to optimal results. FUNDING: The study was funded by the Health Insurance Fund (http://www.hifund.org/), through a grant from the Dutch Ministry of Foreign Affairs.

The effect of health insurance and health facility-upgrades on hospital deliveries in rural Nigeria: a controlled interrupted time-series study.

BACKGROUND: Access to quality obstetric care is considered essential to reducing maternal and new-born mortality. We evaluated the effect of the introduction of a multifaceted voluntary health insurance programme on hospital deliveries in rural Nigeria. METHODS: We used an interrupted time-series design, including a control group. The intervention consisted of providing voluntary health insurance covering primary and secondary healthcare, including antenatal and obstetric care, combined with improving the quality of healthcare facilities. We compared changes in hospital deliveries from 1 May 2005 to 30 April 2013 between the programme area and control area in a difference-in-differences analysis with multiple time periods, adjusting for observed confounders. Data were collected through household surveys. Eligible households ( n = 1500) were selected from a stratified probability sample of enumeration areas. All deliveries during the 4-year baseline period ( n = 460) and 4-year follow-up period ( n = 380) were included. FINDINGS: Insurance coverage increased from 0% before the insurance was introduced to 70.2% in April 2013 in the programme area. In the control area insurance coverage remained 0% between May 2005 and April 2013. Although hospital deliveries followed a common stable trend over the 4 pre-programme years ( P = 0.89), the increase in hospital deliveries during the 4-year follow-up period in the programme area was 29.3 percentage points (95% CI: 16.1 to 42.6; P < 0.001) greater than the change in the control area (intention-to-treat impact), corresponding to a relative increase in hospital deliveries of 62%. Women who did not enroll in health insurance but who could make use of the upgraded care delivered significantly more often in a hospital during the follow-up period than women living in the control area ( P = 0.04). CONCLUSIONS: Voluntary health insurance combined with quality healthcare services is highly effective in increasing hospital deliveries in rural Nigeria, by improving access to healthcare for insured and uninsured women in the programme area.