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ABSTRACT

People in poor countries tend to have less access to health services than those in better-off countries, and within countries, the poor have less access to health services. This article documents disparities in access to health services in low- and middle-income countries (LMICs), using a framework incorporating quality, geographic accessibility, availability, financial accessibility, and acceptability of services. Whereas the poor in LMICs are consistently at a disadvantage in each of the dimensions of access and their determinants, this need not be the case. Many different approaches are shown to improve access to the poor, using targeted or universal approaches, engaging government, nongovernmental, or commercial organizations, and pursuing a wide variety of strategies to finance and organize services. Key ingredients of success include concerted efforts to reach the poor, engaging communities and disadvantaged people, encouraging local adaptation and careful monitoring of effects on the poor. Yet governments in LMICs rarely focus on the poor in their policies or the implementation or monitoring of health service strategies. There are also new innovations in financing, delivery, and regulation of health services that hold promise for improving access to the poor, such as the use of health equity funds, conditional cash transfers, and coproduction and regulation of health services. The challenge remains to find ways to ensure that vulnerable populations have a say in how strategies are developed, implemented, and accounted for in ways that demonstrate improvements in access by the poor.

CHAPTER ONE

INTRODUCTION

1.1 BACKGROUND OF STUDY

Out-of-pocket (OOP) expenditure by households was the most important financing agents through which health expenditure sources channel funds to providers for health services in Nigeria and many other low/middle-income countries.1 The world Health organization (WHO) defined Out-of-pocket payment for health care as, „the direct outlay of households, including gratuities and payments in kind, made to health practitioners and supplies of pharmaceuticals, therapeutic appliances and other goods and services whose primary intent is to contribute to the restoration or to the enhancement of the health status of the individual or population groups. It includes household payments to public services, non-profit institutions and nongovernmental organizations. It also include none reimbursable cost sharing deductions, co-payments and fee-for-service, but excludes payments by companies that deliver medical and paramedical benefits whether required by law or not, to the employee and also excludes payment for overseas treatmen'.2 OOP expenditure on health has been observed through the years to be disproportionately higher among most developing countries than the developed ones. For example,

Nigerian‟s private health expenditure as percentage of total expenditure on health in 2008 stood at 74.7%, out of this OPPs expenditure constituted 95.9%3 while the total government expenditure during this same period stood only at 25.3%.3 This suggests that government and privately organized institutions are not making enough investment in the health of the people which is supposed to be a national priority and that much of the burden of health care is bored by individuals and households.

Out-of-pocket payment for health care is one of the five major ways of financing health care in Nigeria. The others are, government (from all sources including taxes), health insurance (private and government schemes), donor funding from bilateral and multilateral organizations, and NGOs. There is however over-reliance on OPP expenditure as a major source of financing health in Nigeria and in most low and middleincome countries. Even though taxation may to some extent be equitable between the rich and poor, payment for health care is however, non-equitable, since both the poor and the rich pay equally for the same health care service in both public and private health facilities.  The 25.3% general government health expenditure (GGHE) as percentage of total health expenditure (THE) is also contributed to by the poor as tax from their lean resources, even though they are often too poor to afford payment for health services, and many of this poor have become impoverished in an attempt to pay for such health care services,4 either by way of the illness itself (most especially chronic ones needing prolonged and frequent absence from work), or by reduced ability to work, and thirdly by the cost of treatment which is often prohibitive to the poor.  Consequent to this, many families are left with no alternative than to seek for discharge from health facility, which are most often against medical advice. As a result of these actions, such patients continue with their ill health, death, or go into impoverishment on recovery if they ever do so.

They are several and certainly obvious problems with our health care delivery system but, majorly with health care financing. Poor health care financing has contributed significantly to the low patronage of public health facilities. Because the sick often had to pay directly out of pocket at the point of service delivery even though they are almost always unprepared for this kind of sudden expenditure. Unfortunately Nigerian, most especially the poor and middle income earners, do not save for health, possibly because they are not aware of the existence of such schemes or when they do they lack access to this schemes.5

Financing health care is one of the components of the Health system management. It is centered on three interrelated factors. 1) revenue collection, which is the process by which the health system receives money from households and organizations or companies as well as from donors,  2) polling of resources, which is the accumulation and management of revenue in such a way as to ensure that risk of having to pay for healthcare is borne by all the members of the pool and not by contributor individually, and 3) purchasing of interventions, which is the process by which pooled funds are paid to providers in order to deliver a specified or unspecified set of health interventions.6 The objectives of health care financing therefore are to make funds available, ensure appropriate choice and purchase of cost effective interventions, give appropriate financial incentives to providers, and ensure that all individuals have access to effective health service.6  The challenges faced by most low and middle-income countries, such as Nigeria, are those of identifying sources of financing health care and being able to pool these resources together for the general benefit of the citizens. Failure to harness these components of health care financing leads to high poverty incidence and therefore large failure of citizens to utilize available healthcare services.

In Nigeria the average household expenditure on health care between 1999 and 2001 stood at 64.25%, and rose to 68.45% between 2002 and 2005 while the public expenditure on health care stood at 35.7% and 31.65% during these same periods of timerespectively.1,7 This large percentage (68.4%) contribution by households to health care financing is made up of expenditure by both the majority have-not and a few have-much as there is no disparity between what the rich and poor households pay for health care despite the wide difference in their economic status. There are no specific provisions for healthcare schemes for the poor in the society, most especially for those living in the rural areas where the poor of the poorest are found in their numbers. Even where specific free health care services are made available, such as free immunization scheme or family planning, they are equally enjoyed by the rich and the poor. There is also an irony in the implementation of the social health insurance (National Health Insurance Scheme {NHIS}), where those that are in dire need for the scheme scheduled for the second set of people to be reached for the scheme while those who are economically better-off and therefore most likely able to purchase health care enjoy the privilege of being the first to benefit from this scheme.  Therefore it can be subsumed that poor households are at disadvantaged position of paying disproportionately higher for health care than richer households.

Some African countries, e.g. Uganda and South Africa have some exemption methods for the terminally ill and people with HIV/AIDS most especially if such a person is the head of a households. Some other countries have special healthcare package(s) such as, exemption from payment for health care for the elderly or delayed payment for those who are incapable of paying at the point of service8-10. This type of package is almost in nonexistence in Nigeria even though the federal government and some states have some forms of free health care service such as immunization, free antenatal and delivery services for the pregnant women and free treatment bill for the under-5 children but, these packages are not exclusively reserved for the poor.

Low spending on health care by all tiers of government in Nigeria is an important contributor to the high poverty incidence by households. The total government health expenditure (TGHE) as a proportion of the total health expenditure (THE) was estimated to be 18.69% in 2003, 26.4% in 2004 and 26.02% in 2005 while household health expenditure (HHHE) as a proportion of THE was 74.02% in 2003, falling to 65.73% in 2007 but went up to 67.22% in 2005.1 Not only was TGHE low but also that the rate of increase per annum was rather too low and slow. Comparing the Nigeria case to some other African countries such as Zambia, where HHHE was 21.20% of the THE in 2002 while corresponding value for Kenya was 51% and Egypt was 60% in the same year1.It‟s evidently clear from this that there is unwillingness on part of Nigeria government to increase its expenditure on health. This apathy may not be peculiar to Nigeria as it has been observed that, there is general apathy among government of developing countries to improve spending on health care. For instance, in 1994 the  global expenditure on health total US $ 2.3 trillion, with high-income countries spending about US $2.0 trillion of this total even though they accounted for only 16% of the world population. Developing nations on the other hand spent only 11% of the total global spending on health but accounted for 84% of the world population.11

This wide gap between developed and developing nations might have been contributed to by the enabling environment and incentives for independent health insurance organizations to participate in health care for its citizens. The level of participation by private insurance institutions in the United Kingdom, USA, and Uganda stood at 55%,

While in Nigeria, between 2003 and 2005 health insurance contributed at only 3% of the THE. Health insurance is meant to improve access to health care, thus promoting good health. Reasonable access to health care encourages individuals to seek health maintenance services more regularly than they otherwise would, thereby prevent potentially serious illnesses and protect individuals from financial hardship that may result from large or unexpected medical bills.  Health insurance can be obtained from private organizations or from government agencies.6It was in response to the urgent need for health insurance that the Federal Government set up the National Health Insurance whose bill was passed into law in 1999 although it only became operational in 2006. This scheme is intended to be a tool for achieving health related Millennium Development Goals (MDGs) but, the target group are not being reached via this scheme. For example, reduction of infant and maternal mortality rates, those who contribute most to these high rates (poor households) are yet to be reached with the scheme12. Even though there are plans to expand the programme to reach the informal sector and therefore the rural poor, the actualization of this goal is not likely in the immediate feature in view of the rather slow phase of implementation and also for the lack of pre-existing structures, that could serve as the lunch pads for the programme as it was done in Ghana. Ghana started the mandatory health insurance that was introduced as a result of increased request for an alternative health care financing system for its PHCs,  however, prior to this there were informal community and private trials of various health insurance schemes, i.e. by 2003 just before its introduction, there were at least 67 district wide schemes and 189 HMOs ran by communities, schools, churches and NGOs that eventually collapsed into the national health insurance scheme thereby giving it wide range of coverage and reaching the informal sector was made with much ease.13 It could therefore be said with some degree of certainty that community organizations for health are important tool for reaching rural households, and could also play the role of mobilizing contributions in rural communities where formal social security scheme  cannot reach because of the difficulty of assessing and collecting contributions. The community can be very effective in mobilizing material and human resources for the expansion of the national health insurance scheme.

The alarming  private share of expenditure on health in Nigeria is all more alarming as most of it takes place via non-pooled out of pocket expenditure. This seems to have arisen from limited awareness by communities and groups about the potential impact of prepayment financing which spreads risk and pool fund on issues of health care equity, financial protection and social safety-net improvement.6

These challenges posed by high poverty incidence on health are likely to get worst in the face of global economic down-turn and the ever increasing poverty in lowincome nations. Poor households without financial protection will also continue to experience diminished access to good health care service. Some may resort to leave the sick untreated or go for low quality health care and when these options fail such household could end-up spending catastrophically and, most of often than-not culminate in further impoverishment of such households.14 Expenditure is said to be catastrophic when household expenditure or contribution to the health care system exceed 40 percent of income remaining after subsistence needs have been met.15 This study was thus conducted with the view to determine the level and incidence of poverty incidence on health care by house-holds in Keffi, a semi-urban community of Nasarawa State, North-central Nigeria.

         1.2   PROBLEM STATEMENT

The cost of health care service in both public and private health facilities has sky rocketed in the recent past and it seems this will continue in years to come except an urgent intervention is put in place. While the ability to purchase health care is diminishing there is increasing poverty in the country (Nigeria), as it is the case with most developing nations. Therefore there is the need for urgent intervention at all levels and quarters to bring about access to all, no matter their position or where they live.  

The continuous inability of the sick and households to pay for health services is a common phenomenon in many health facilities across the length and breadth of Nigeria. This is, however, more common among the poor rural households and semi-urban dwellers. The situation may be so precarious that the sick‟s relation may have to sell some properties of the sick or of the household in order to pay for medical bills. In other instances loans with high interest rates may be obtained on behalf of the sick and this are usually not devoid of the consequence of impoverish of both the sick and the household. In extreme cases of poverty the sick are often left at home without treatment or if already on treatment at a health center she/ he is taken home and left at the mercy of death. These unfortunate happenings could be attributed to lack of commitment on part of government at the three levels, federal, state and local governments. For example, the financial contribution of all level of government was only about 36% between 2002 and 2004

while household have a share of an average of 64% within the same period1,5. This has been the pattern over the last 15 to 20 years.  The lack of health insurance for the poor is another major contributing factor. The National Health Insurance Scheme that is meant to alleviate the burden of high household expenditure on health is yet to reach the poor who need it most urgently, and the probability of reaching them in the near feature is almost not feasible because of the slow phase of attempt at implementation and for the lack of commitment on the part of government at all levels. The almost nonexistence of Private health insurance has further compounded the problem. As at the end of 2006 not many health insurance organization were in existence, even the mutual health organizations that were operating in early 1990s are almost in nonexistence today, except a few in Lagos State, e.g. Jas Medical Service in Mushin and Lawanson in surulere, Lagos.16 The other contributing factor and probably the most crucial for now is the lack of savings for Health (or illness) by households. It could be said that two factors are responsible for the failure to save for health. First, the high level of poverty in the country, where 60% of its citizens live below poverty line and secondly, there is significant level of lack of awareness among Nigerians and it‟s households that they and the community could come together and save for their health care and thereby minimize the ugly, incessant and unnecessary incidence of catastrophic expenditure on health care and its impoverishment.

It‟s intended that this study will determine the level and frequency of household expenditure on health care and also explore the resources available to households in Keffi that could improve access to health care that are affordable, feasible, and sustainable.

         1.3 JUSTIFICATION 

Out-of-pocket payment for health care by households has been estimated by several studies and estimations to have contributed between 64 and 70 percent of health care financing in Nigeria and has largely contributed to the inability of households to access adequate and desirable health care be it in the public or private1. This unfortunate situation has not only contributed to the high morbidity and mortality but has also impoverished many households.

The National Health Insurance Scheme (NHIS) introduced to alleviate this high out-ofpocket expenditure on health is still not accessible by majority of those in the informal sector and the probability of reaching these sets of Nigerians in the nearest feature seems more of mirage than reality. It is in view of the urgent need to finding solution(s) to these challenges that calls for the necessity for an alternative, at least for now. Community Health Organization (CHO) and other forms of health insurance that are almost in nonexistence need to be explored with the aim of establishing a less-burdensome health care payment mechanism for households in Keffi.

         1.4   RESEARCH QUESTION

Does poverty incidence significantly affect household access to health care? 

         1.5 AIMS AND OBJECTIVES 


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