The Effect of Poverty and Access to Health Care

The Effect of Poverty and Access to Health-Care

Chapter One

AIMS AND OBJECTIVES

General objectives

To determine the level and frequency of poverty incidence on health care among households in Keffi

Specific objectives

To determine the source of household financing for health care.
To quantify the proportion of household income spent on health care
To measure the perception of household on the best method of payment for health care services.

CHAPTER TWO

LITERATURE REVIEW

Many low and middle – income countries over the years continue to seek for better ways of financing their health systems. Common among many of these systems is that, present financial methods do not mobilize sufficient resources to provide the needed level of health care for the citizens. Much of the available resources are not pooled to provide any significant protection against households expenditure variance or channeled through some form of pre-payment mechanisms, and the scare resources that are mobilized often do not lead to value for money in terms of the health care on which it is spent.

Countries need to mobilize sufficient resources to provide essential health services for their population, reduce inequalities in the ability to pay for those services, and provide financial protection, against impoverishment from catastrophic health care cost through explicit policies affecting the three financial functions of collecting revenues, pooling risk, and purchasing of goods and services. Developing countries, particularly low – income countries, face severe challenges in mobilizing sufficient resources to meet even basic service needs, while middle–income countries focus more on providing universal coverage to their populations. Various mechanisms for risk pooling and prepayment are possible for countries at all income levels, but this depends much on problem associated with the structure of a country‟s economy, as well as its financial, and political capacities.¹⁸

Despite the increase in health expenditure over years millions of peoples suffer financial catastrophe. 150 million people globally suffer financial catastrophe each year and 100 million are pushed into poverty because of direct payment for health services.^19-21 This indicates that a wide spread lack of financial risk protection, a deficiency that affects low income countries most, but by no means limited to them. The global health care expenditure have risen from 3% of world GPD in 1948 to 7% in 1997 and recently to 9% in 2010,^6,11 yet millions are pursued into further poverty in attempt to pay directly for healthcare services. Therefore, health care financing is much more than a matter of raising money for health; it is also a matter of who is asked to pay, when they pay and how the money raised is spent.

HEALTH CARE FINANCING SYSTEM

The purpose of health financing is to make funding available as well as to set the right financial incentives for providers, to ensure that all individuals have access to effective public health and personal health care. This means reducing or even eliminating the possibility that an individual will be unable to pay for such care or will be impoverished as a result of trying to do so.

To ensure that individual have access to health service, three interrelated functions of health system financing are crucial: revenue collection, pooling of resources and purchasing of interventions. It does not just stop at that but there are challenges of having the necessary technicalities, organizational and institutional arrangements so that such interaction will protect people financially the fairest way possible, and to set incentives for providers that will motivate them to increase health and improve the responsiveness of the systems.⁶

CHAPTER THREE

METHODOLOGY

Background of the Study Area

Keffi, the head quarter of Keffi Local Government Area council is a semi-urban settlement situated at the western part of Nasarawa State, North central zone of Nigeria. The town is divided into 8 political wards that are further grouped into smaller unit of zones. From the 2006 population census Keffi had an approximate population of 92,664 persons made up of 47,801 males and 44,863 females. The total numbers of households in the main town, keffi, is currently not available but the local government area has a total of 16,664 households and the modal household membership being one. The major ethnic groups are Hausa, Mada, Eggon, Igbos and others minority ethnic groups. The dominant religions are Christianity and Islam. By occupations its dwellers are majorly civil servants, subsistent farmers, traders, and artisans. Others are medical personnel of diverse professions such as, medical doctors, nurses, pharmacists; medical laboratory scientists employed in the public and private sectors. The town has some reputable health facilities, for example, one tertiary health institution (Federal Medical Centre), one General Hospital, four Private Hospitals, 8 Primary Health Care centers, numerous private clinics and one School of Health Technology. In addition to these are a few pharmaceutical outfits and sizeable number of patent medicine stores manned by either qualified or unqualified personnel, doting several streets and corners of the town. Traditional healers and religious prayer houses are often visited by many of its inhabitants for the purpose of obtaining treatment for their illnesses. This settlement has some characteristics common to most towns and cities in developing counties such as poor water supply, lack of proper refuse collection and disposal, and poorly supervised health staff and facilities. While some areas are dominated by standard houses and infrastructures (mainly at the outskirts) and Government Reservation Areas (GRA), other areas are majorly urban-slums, squalors and ghettoes.

Study Design

The study is a descriptive cross-sessional design.

Study Population

The study population shall be households in keffi town.

CHAPTER FOUR

RESULTS

The data analysis and results presented in this chapter are based on the 316 out of 324 copies of questionnaires that were collected. Eight were improperly captured; therefore the response rate was 97.5%. 171 households had at least one member who was sick within the period of the study.

CHAPTER FIVE

DISCUSSION, CONCLUSION AND RECOMMENDATION

DISCUSSIONS

The result showed that nearly all households in the studied population utilized personal out-of-pocket source to settle treatment bills while only a few, who are civil servant, paid through social health insurance scheme. This finding of low NHIS uptake and rates was similar to the finding of a study in Ebonyi and Enugu states that centred on investigating the determinants of \ spending and strategies for coping with payments for healthcare in southeast Nigeria by CA Onoka et al which showed that usage ranged between 68.4 and 96.9 per cent and health insurance coverage of less than 1%⁵⁰in different communities of the states. The finding in this study of 1.8% NHIS coverage was less than the rate reported in the 2008 National Demographic and Health Survey (NDHS 2008)⁵¹that gave a figure of 3%. This could be attributed to the lack of uptake of NHIS by the state and local governments for their employees. However, based on the presence of some federal institutions, such as the Federal Medical Centre, and civil servants who work in Abuja but live in keffi, it was expected that the figure could have been higher. In addition to this, the significantly high percentage (41%) of households headed by civil servants in the community was also expected to have increased the level of uptake of the NHIS, but for the nonparticipation of the state and local governments in the scheme. The other reasons that could be adduced for higher national figure of NHIS coverage as compared to the finding in this study is that, bigger cities and towns with high number of federal civil servants, states that have started implementing the programme and private organizations participating in the scheme could have contributed significantly to this difference. There is also the possibility that civil servants in this study area live at high concentration in one part of the town (ward) than the others thereby reducing the chances of being among the selected households in the other three wards.

The average income per household in this study was much higher than the current Nigeria

Federal Government minimum wage of two hundred and sixteen thousand naira (₦216,000) per annum. However, those on the lowest income side are most likely to earn far below this mean income as signified by the large standard deviation (SD) that was above four hundred thousand naira. Taking the mean income and possible lowest income based on the naira value of the standard deviation [₦620,616:67(mean income) minus ₦400,902:63(SD)] such a household is left with ₦219,714 per annum or ₦18,309:50k per month. With the current exchange value of about 158 naira to a dollar, this will amount to less than a dollar/person/day for an average keffi household. This is below the “least poverty line” of US 1.25 Dollar per day for those considered extremely poor. The average annual expenditure on health stood at 39,000 Naira per HH per annum but, with a large standard deviation of 25,499 Naira, this gives an expenditure on health of about ₦3250 naira per HH per month. This amount could be used up by one person even if it is for the treatment and investigations for uncomplicated malaria alone, not to mention of a four member HH. This figure was, however, consistent with the findings of Onwojekwe and others in their study in Ebonyi and Enugu states among city HHs that spent about ₦1320 per week on health care services⁵⁰. It was also observed that those of the lowest quintile, farmers and HHs with no formal education spent disproportionately higher on health care than those of the higher quintiles and those with formal education. For example, the lowest quintile spent three times disproportionately more than the highest quintile, while farmers spent five times disproportionately more than civil servants. The explanation for these differences in proportion of expenditure on health was that, some professions earn less but may obtain health care services from the same source and pay same charges for similar services as other professions that earn higher income.

There was significant statistical association between educational attainment and the proportion of income spent on health care. Those HHs headed by those with non-formal education spent twice disproportionately more than HHs headed by those with formal education. This might have been responsible for their reduced capacity to purchase health care without catastrophic expenditure (for definition of catastrophic expenditure see page 8), because those who spent catastrophically on health care in this study were mostly of the lowest income and wealth quintile groups. These findings were also consistent with the finding of Tin Tin Su et al in their investigation into the catastrophic expenditure for health care in low-income society in Nouna district of Burkina Faso. In their investigation they found out that among other factors economic status was the most important factor leading to catastrophic expenses.⁵² While the figure of 3.5% catastrophic expenditure was higher than that reported for some countries of the OECD countries, with weighted mean catastrophic expenditure rate that was barely 1% as reported in the WHO, World Health Report 2010 on Health system Financing.⁵³ Nonetheless, the finding in this study was comparable to the 4.6% obtained by Jane Chuma and Thomas Maina in their study of the Catastrophic health care spending and impoverishment in Kenya.⁵⁴Onoka and Onwojeke reported 15% catastrophic rate in Enugu and Anambra states in their study of “Measuring Catastrophic Health Care Expenditure in Nigeria”⁵⁰ but fixed their catastrophic threshold at 40% of expenditure after other essential needs have been met contrary to this study where the catastrophic rate was based on 40% expenditure on health of the total income. The low catastrophic rate by the OECD countries could be as a result of their health system financing that has significant mix of privatization, social health insurance and OOPs, contrary to Nigeria‟s over dependence on OOPs. On the final analysis the most disadvantaged groups in having access to good health care were the low in-come/lowest wealth quintle, farmers and those with no formal education who are in summary, poor.

The prominent factors influencing most households‟ access to health care services were delays at service points and money for services rendered including drugs. However, the influence of these factors defer among different socio-demographic groups. The lower income groups, the farmers, and those with non-formal education had problem with money for services, while those with formal education, civil servants and higher income groups had problem with delay at points of services. This also pointed in the direction of income being the main determinant to access health care among the poor, most especially if the preceding discussions are put into consideration. For example, the earlier group failed to access health care because of low-income just as it was observed by several other studies in a wide variety of developing countries, that the introduction of user fees or increases in prices can lead to decreased utilization and that this effect can be larger for the poor.^55-58 Those who considered time factor as a major hindrance to access health care were mainly civil servants who were probably in a hurry to return to their offices or duty posts so as to meet up with time permission granted them ab initio. In conclusion income among those who are financially poor was the main differential factor while time was the major factor among those who were most likely able to pay for services rendered.

Out of the 316 households in this study, 194 (61.4%) showed interest in having at least one type of prepayment health care scheme. It was however, not certain why the remaining 39.4% did not indicate interest in prepayment scheme for health care. this could be due to lack of proper and adequate information or knowledge on what prepayment means. There were indications that the studied community lacked adequate awareness on the types and methods of operation of health care insurance, as evident by the show of interest for employment based social health insurance scheme by those in the non-formal sectors who are the ones not presently enjoying the services of the NHIS . In agreement with the above assertion which could equally be associated with the lack of awareness, was the lower percentage of desire for employment based social health insurance by civil servants who were expected to clamour for such a scheme. For example, 41% of households were headed by civil servants but only 37% of this indicated interest in employment based social health insurance scheme. On the final analyses the most acceptable methods for payment for health care services among the studied population were community and employment based social health insurance schemes. The reason for these findings may not be unconnected with the low awareness of the benefit of national health insurance scheme and possibly also for reason of Keffi being significantly more of a traditional community. Additional research works need to be undertaken for a clearer picture of this unexpected finding.

CONCLUSION

The main source of financing health care among keffi households was low but, the proportion of income spent on health care was not high. The income to households had much influence on the poor‟s access to health care, however, majority of households were much willing in participating in prepayment health care financing schemes and programmes.

RECOMMENDATIONS

There is urgent need for introducing social health insurance scheme by all tiers of government for their staff without further delay, as this will go a long way in making health care accessible and affordable for its work-force and family and thereby reduce the high level of OOP expenditure on health.
Those in the non-formal sector are yet to access the services of social health insurance because of none commencement of the proposed Community Base Social Health Insurance Programme. It is here recommended that the federal government should fast track the commencement of this programme and the other tiers of government should key in immediately.
There is also the need of expanding The Poverty Alleviation Programmes in this community and state-wide so as to improve the earning power of households and therefore enhanced their purchasing power for health care services.
Attainment of higher level of education was associated with improve income and therefore increase access to better health care therefore, Keffi households stand to benefit better health care in the long run if they encourage their children to attain higher level of education.
Members of groups and associations should be encouraged to start contributory health financing schemes even before the commencement of the CBSHIP as this could become the launch pads for the programme.

REFERENCES

Soyibo A, Olaniyan O, Lawanson A.O. Incorporating sub-National Health Account of States: National Health Account of Nigeria 2003 – 2005, Main Report
World Health Organization, Associated terms, out – of – pocket spending by private households (OOPS): National Health Account, World Health Organization Statistical Information System (WHOSIS) 2008
WHO Health Expenditure, WHO Health Statistics, Geneva, Switzerland, 2011
World Health Organization, Direct payment, where are we now? Universal coverage, Health system financing, World Health report 2010, page 4.
Federal Ministry of Health, National Health Financing policy, Federal Republic of Nigeria Introduction, 2006, pages 6-9.
World Health Organization, who pays for health, Health system financing improving performance, World Health Report, Geneva, 2000, 95 – 97
Federal Ministry of Health, Federal Republic of Nigeria, National health Financing Policy Zero Draft 2006: 6.
Nguyen TH, Ha LT, Rifkin SB,Wright EP, the pusuit of equity: a health sector case study from Vietnam health policy. 1995. Pages 191-204
Wagstaff A. Poverty and health sector inequalities: Bulletin of Horld Health Organisation 2007 pages 97 – 105
Nabajongo I. Desmet M. Karamgi H. Kadama PY.Omaswa FG. Walkero M, abolition of Cost saving is pro-poor: evidence from Uganda. Health Policy and Planning 2005 pages 100-108

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