This study assessed the consequences of the suspension of a community-based health insurance program in Kwara State, Nigeria. This suspension was due to the preparations required for a major Government policy change towards the commencement of a state-wide health insurance program. For this reason a unique situation emerged, which allowed for a ‘reverse intervention’ evaluation of a community-based health insurance. This was performed by a mixed method study on both the former enrollees and participating healthcare providers.
First of all, it was observed that despite the suspension of KCHIP, the large majority of former enrollees still preferred to use the KCHIP health facilities. This was mostly due to extended positive experiences and relationships previously established with the KCHIP health facilities, perceived quality of care and geographic proximity. The quality upgrades previously performed with the providers as part of KCHIP most likely contributed to this observation. In addition to facility infrastructure upgrade, other quality improvement interventions included implementation of treatment guidelines and protocols for waste management and hospital infection control, training of staff in guideline-based care and adequate medical file keeping, hospital renovation, upgrading of laboratory equipment and training of laboratory staff in basic laboratory testing and assurance of continuous essential drug supplies (10,11). All in all, there are basically few alternative options of similar medical quality available for Kwara patients. This corroborates the propensity of community-based health insurance, when combined with quality improvement of medical services, to remove barriers to UHC (4).
This study also demonstrated that three-quarters of the former KCHIP enrollees reverted to OOP payment for their healthcare services. Remarkably, and apparently as a result of the established relationships with KCHIP facilities, the remaining one-quarter of enrollees were treated for free or were allowed to make partial or tranche-wise payments, even with private healthcare providers. This could be an indicator of build-up of social benefits from the KCHIP, though at a certain cost to the healthcare providers. The high rate of reversal to OOP obviously endangered the original insurance aspirations and benefits of KCHIP (6,8,10) and it also represents a potential threat, which can plunge enrollees into catastrophic health expenditure (8,15).
We show that of the two-thirds of former enrollees who experienced constraints to pay for healthcare services, the KCHIP suspension as well as the general economic recession in Nigeria were mentioned as most important perceived causes. Economic recession has been reported elsewhere to cause reduction in individual expenditure and health insurance consumption power (16)[14]. we found that the KCHIP suspension had additional and immediate consequences for former enrollees, leading to the adoption of financial coping mechanisms like personal savings, donations and borrowing. Respondents also reported receiving support from financial or social groups in the form of “ajo” contributions, religious groups, community groups and cooperative groups. These were beneficial to individuals who required funds for sickness. Such financial/social groups could be effective coping strategies in terms of improved household income (17).
The male enrollees living in the rural communities reported more difficulties paying for healthcare services after the program suspension. This is in line with a study on catastrophic health expenditure in Nigeria, which concluded that female-headed households were less likely to incur catastrophic expenses compared to male-headed households (18). This may reflect a lower access to healthcare services and higher foregone formal care among women compared to men (19,20). The Yoruba ethnic group appeared less constrained to pay for healthcare services after the suspension.
Living in rural communities of Nigeria is associated with poverty, poor infrastructure and lack of geographical and financial access to healthcare services (21). Our findings on the wealth quintiles that indicated a significant socio-economic gradient in access to healthcare after suspension looks similar to the inference by another local study (22), which concluded that the richer quintiles indeed experienced less catastrophic health expenditure. Enrollees who experienced an acute illness or injury in the preceding 12 months prior to the suspension of enrollment had reduced odds of being able to cope with the suspension of the program. A previous study in Kwara State on spending for non-communicable chronic disease (NCCD) reported health expenditures relative to annual consumption of the poorest quintile exceeding those of the highest quintile 2.2-fold, and the poorest quintile exhibiting a higher rate of catastrophic health spending (10.8% among NCCD-affected households) than the three upper quintiles (4.2–6.7%) (19). Several Nigerian studies (22) also reported increased risk of incurring catastrophic health expenditures for household members with non-chronic illnesses. This finding implied that both enrollees with acute illnesses and chronic disease are bound to suffer the consequences of the program suspension.
While there were no serious consequences with respect to the range of service provision, a significant reduction in patient load in (almost) all of the KCHIP facilities was observed. However, there were slight spikes on patient load around the wet months of the year, which corroborated seasonal patterns of seeking healthcare (mostly related to malaria season and harvest time). All health facilities’ revenues dropped considerably as enrollees exited the program. Private health facilities experienced higher drops in revenue after KCHIP suspension. Public facilities still received stipends from the government to run their services, which cushioned the effects. Some public health facilities even reported an increase in revenue generation because of the removal of (national) insurance program restrictions on the direct billing of the patients and possibly also due to some shift of private patients towards the public sector. Private health facilities disproportionately suffered a reduction in staff strength, motivation and productivity. This resulted in downsizing of staff in many of these facilities. In addition, we observed a downward trend in drug purchase among the private health facilities, which remained unchanged in public facilities that kept benefiting from supply of essential drugs from the Ministry of Health. Finally, the suspension of KCHIP was reflected by clear downward out-patient department visits, but in-patient visits remained the same. This is probably due to the severity of medical reasons for an in-patient visit, that cannot be ignored or postponed. Consequences for OOP expenditures are corresponding.
In the literature, suspending an impactful health insurance program is an uncommon policy decision. This is probably due to high political sensitivity and the legislative bureaucracy that such action will cause. In January 2016, the Qatari government suspended a State-financed mandatory national health insurance program due to inability to sustain the exclusive funding of the program because of a fall in global oil prices (23). Experts expected in the short term a larger private sector involvement in the Qatari healthcare coverage, while in the long term an uncertainty regarding payment of Qataris' medical bills and UHC. The suspension of the Qatari health insurance program adversely affected hospitals, health centres and patients, which caused negative outcry among the population (23). Similar observations are made in Kwara with respect to deteriorating access to healthcare, which happened much rapidly due to the weaker healthcare infrastructure and poverty status of the population. Shifting from fragmented smaller-scale community-based health insurance schemes to a larger State-owned insurance program is a precarious process. Lessons can be learnt from elsewhere in Africa, like the development of the National Health Insurance Scheme (NHIS) in Ghana (24), the political path to impactful community health insurance in Rwanda (25) and the transition of the improved Community Health Fund (iCHF) into a National iCHF in Tanzania (26). Common recommendation is the introduction of a transition phase with clearly defined services before the new larger-scale insurance package is introduced, providers are assigned and financial coverage is arranged for instance through tax systems, like VAT such as in Ghana (24).
This paper demonstrates that temporary suspension of health insurance in the absence of transitional measures has consequences for clients and healthcare providers, but it also provides opportunities to learn lessons that help re-engineering schemes to improve effectiveness and efficiency. For example, it was learnt that transition periods can benefit from leveraging on previously built social capital, including the network of relations between former enrollees and healthcare providers, as well as the support from particular social groups (religious, community and cooperatives). It was also learnt that refurbishment of health facilities and quality improvement of services during the previous phase of community-based health insurance was appreciated also during suspension of the KCHIP, with people continuing to visit KCHIP healthcare facilities. At the policy level, Kwara State worked to adopt a law that makes health insurance mandatory for all inhabitants and requires that the State government commits one percent of its revenues to finance health insurance. In addition, during the transition phase Kwara State started the process of setting up a dedicated State Health Insurance Fund that pools financial contributions from diverse sources, including the State government, the Federal Government of Nigeria (particularly Ministry of Health and National Health Insurance Program) and individual enrollees.