The path to UHC: The Lessons learnt from transitioning from a Community-based to a State-wide health insurance Scheme in Nigeria.

Background Social health insurance has been widely proposed as a key strategy in moving towards universal health coverage. This paper reports on the transition of a community-based health insurance scheme in Kwara State, Nigeria, in 2016 to a state-wide social insurance program. Specifically, it analyses the consequences of the temporary suspension of the community-based insurance scheme during the transition period on healthcare utilization and financial protection. Methods A mixed methods study was carried out in 2018 using a semi-quantitative cross-sectional survey amongst 600 clients, in-depth interviews with 24 clients and 29 participating public and private healthcare providers. Results Most former enrollees (95.3%) kept using Kwara Community Health Insurance Program (KCHIP) facilities, even after the suspension of the program. Over 70% of respondents reverted to out-of-pocket (OOP) payment for healthcare services and 67% experienced constraints in payment for healthcare services after suspension of the program. Most common coping mechanisms for healthcare payment was personal savings (63.3%). Seventeen of 29 facilities recorded a decrease in revenue after suspension of the program. Being male (OR=1.61), respondents living in rural communities (OR=1.77), those who use KCHIP exclusively (OR=1.94) and acutely ill respondents (OR=3.38) had increased odds of being constrained with the suspension of the program. Conclusion After suspension of the KCHIP, many enrollees and health facilities experienced constraints. Enrollees’ most important coping mechanisms remained personal savings which has more likelihood of pushing them to catastrophic expenditure.


Introduction
With only a third of the population in developing countries having access to affordable healthcare, universal health coverage (UHC) has become a major policy prescription in global health. The progress towards UHC involves setting ambitious goals for expanding access to decent health services based on establishing a greater reliance on risk-pooling and prepayment mechanisms to finance health, stimulating investments in healthcare infrastructure and quality, and building human resources and skills for health. The World Health Organization (WHO) estimates that more than half the world's population does not have access to the health services they need, and 100 million people suffer financial catastrophe every year due to out-of-pocket (OOP) expenditures for unexpected healthcare (1).
Introduction of a health insurance program is one of the ways to enhance access to healthcare services and to protect individuals from catastrophic health expenditures (2). Financing healthcare through a tax-based system (which is also a form of riskpooling) is difficult as many Low-and Middle-Income Countries (LMICs) are struggling to mobilize sufficient resources. As a result, OOP expenditures remain high and in combination with poor healthcare services form an important barrier to UHC. How to successfully roll out health insurance on a large scale and ensure sufficient take-up in LMICs is an outstanding question (3,4).
In Africa, more than half of all healthcare expenses are covered through OOP payments. For example, in Nigeria -the most populous country in Africa, with a population of almost 200 million -there are substantial inequalities in access to healthcare with 72% of health expenses paid OOP and only about 4% of the people, mostly in the formal sector, having access to health insurance today (5). Nigeria accounts for 2% of the world population but contributes to 14% of maternal deaths and 23% of malaria cases [2]. To address these burdens, Kwara State, one of the poorest States in Nigeria, with the support of PharmAccess and the Netherlands Health Insurance Fund (HIF), launched a subsidized Community Health Insurance Program in Kwara (KCHIP) in 2007 (6)(7)(8). By the year 2015, a total of 347,132 people and 42 public and private healthcare facilities participated in KCHIP (Fig. 1).
The impact of KCHIP has been assessed over time through various studies well as substantial benefits in terms of improved health outcomes especially in relation to chronic diseases like hypertension (10), and maternal and child care (11). Similarly, OOP expenditures significantly decreased by 50% among enrollees, thus securing more financial protection in the medium run (7,9). It was also found to increase awareness about health status (9,12). Additionally, it was demonstrated that the program can deliver a basic quality healthcare coverage at US $28 per person per year, compared to the WHO benchmark of US $60 and Nigeria's total health expenditure per capita of US $115 (8).
An important feature of KCHIP was that there would be incremental financial commitment and ownership of the program by the Kwara State Government over time. The program was aimed at synergizing with the Nigeria National Health Insurance Program (NHIS) with a view to attaining UHC for the State (13). In January 2015 ( Fig. 1), the program partners signed an agreement to transition KCHIP to the Kwara State Health Insurance Program (KSHIP). Pending this arrangement, KCHIP enrolment was temporarily suspended while designing a new insurance product and premium to be introduced and deployed on a state-wide level. Whereas in January 2016, KCHIP was active in 11 out of the 16 Local Government Areas (LGAs) in Kwara State and recorded a total enrolment of 139,714 clients, these clients were not renewed over the course of 2016. This resulted in a gradual drop-out over the year with no clients insured by January 2017 (Fig. 1). Therefore, a unique 'reverse insurance intervention' situation emerged, which is evaluated in this study. This paper describes the consequences of suspension of KCHIP in Kwara state, Nigeria, in wait of a state-wide health insurance, and analyses the effects on healthcare quality, utilization and ability to pay for healthcare among former enrollees, as well as the consequences for formerly participating KCHIP health facilities.

Methodology Study design and study population
In August 2018, about 2 years after suspension of KCHIP (Fig. 1), a mixed method study was carried out among KCHIP former enrollees and healthcare providers in Kwara State, Nigeria. Using multi-stage random sampling, we recruited 600 previously insured respondents for a semi-quantitative cross-sectional survey to obtain data on socio-demographics, healthcare utilization, enrolment status, healthcare constraints and coping strategies since suspension. Only adults (18 years and above) were included in the study, of whom a purposively selected 400 had accessed care in a KCHIP healthcare facility in the preceding 12 months while 200 being not insured in the past 12 months. Of those participants who have accessed healthcare, half (200) were selected who had in addition to other health conditions been seeking chronic care, maternal care and care for acute conditions. In addition, in-depth interviews (IDIs) were performed among 24 purposively selected former enrollees and among 29 health facilities' managers of participating KCHIP facilities (19 public, 10 private). IDIs explored the effects of the program suspension on both healthcare utilization by former enrollees and their coping mechanisms, and health facilities' service provision. Inclusion criteria for IDIs were participant age (18 years and above) and at least once utilization of pertinent healthcare in the past 12 months. Health facilities' clinical records were reviewed as part of the observation checklist within the qualitative data tool used.

Sampling and Data collection
Quantitative study: We recruited a total of 600 respondents whose health insurance policy had expired at least 4 months prior to the end of December 2016. Multi-stage sampling was used, selecting 5 Local Government Areas (LGAs): 2 from Kwara South, 2 from Kwara North and 1 from Kwara Central senatorial zones. Respondents were selected randomly with the KCHIP enrollment database serving as sampling frame after LGAs were allocated proportionate to constituent population sizes (with total enrollment in the 5 LGAs in January 2016 being 73,438). An additional 30% was added from the sample frame for each LGA to cater for non-response and untraceable respondents. The selected respondents were traced in the community (with the help of community mobilizers) and interviewed by trained interviewers.
The questionnaire captured data on respondents' socio-economic characteristics, morbidity patterns, healthcare access and utilization in the preceding 12 months.

Qualitative study
We conducted two rounds of IDIs among former enrollees and facilities' managers.
The enrollees' interviews were conducted among 24 purposively selected adults across 9 selected LGAs cutting across the 3 zones of Kwara State. The selection of former enrollees into the IDIs was carried out in and around the health facilities using a pretested interview guide. The facility managers' interviews were conducted in KCHIP facilities among the officers-in-charge (or the Medical Director). This comprised all 29 Enhanced Community Based Care (ECBC) health facilities (19 public, 10 private) spread across 9 LGAs; 13 health posts providing remote care services were excluded from the study because they were already linked to records of the 29 ECBCs.

Data Analysis
The quantitative data entry platform was designed using Open Data Kit (ODK), while the data was entered using Kobo Toolbox (14)and later exported to Statistical Package for Social Science (SPSS) for analysis. Simple logistic regression was used to explore the predictive factors of the constraints in the ability to pay for healthcare services after the program suspension. The level of significance was set at a p-value of < 0.05 complemented with 95% confidence interval (CI). Qualitative interviews were transcribed and thematic analysis was carried out. The results of the former enrollees' IDIs are reported together in context of quantitative data.

Socio-demography of the respondents
The respondents had a median age of 43 years and 74.5% were women (Table 1).
Close to half of the respondents did not have formal education (42.5%); 77.2% were married, 17.2% widows. About three-quarters of the respondents (73.8%) lived in semi-urban areas ( Table 1). The respondents were majorly Yoruba (64.5%) and Nupe (32.2%) ethnic groups, while Islam (83.2%) was the predominant religion amongst them. The respondents were equally spread over the wealth quintiles, with wealth calculated as annual per capita consumption of food and non-food items. Consequences of (re)enrolment suspension on households The survey shows that the far majority of former enrollees (95.3%) still kept using a KCHIP facility, even after the suspension of the program ( Table 2). This observation was confirmed by IDI statements like: "the hospital has very friendly staff" and "I won't go to another facility because I have confidence in the doctor here". After suspension of KCHIP, 74.0% of respondents mentioned they reverted to OOP payment for healthcare services, mostly remaining at the same private KCHIP facilities. The others who were not able to pay OOP often appeared fully (4.2%) or partially (21.8%) exempted by the private providers from paying. The IDIs revealed that for many patients this was due to friendship and cordial relationships built over the years with health workers at the KCHIP facilities. For other respondents the KCHIP facilities allowed to pay in tranches for reasons of empathy and familiarity. Most common coping mechanisms for payment according to the survey were personal savings (63.3%), donations from friends and families (34.7%) and borrowing (11.8%). Other coping mechanisms included proceeds from petty trading (25.8%), money given by husbands (19.7%) and money received from children (4.5%). According to the IDIs, the most commonly identified coping mechanism was the use of family savings to offset health facility bills while others had to borrow from friends and family members, including seeking assistance from children in paying hospital bills. The quantitative data showed that specific social groups offered health benefits to members such as donations during episodes of illness and loan facilities to offset medical bills. These were (   (Table 4). The respondents with acute illness or injury in the preceding 12 months also had increased odds (OR = 3.38, 95% CI = 2.309; 4.939). Consequences of the suspension of (re)enrolment on the program health facilities: Health providers' interview report and hospital records review After suspension, 24 of 29 health facilities claimed the quality and quantity of services provided remained the same while 5 confirmed reduction in service provision. In the past, more than two-thirds of the health facilities claimed they experienced increased patronage and service utilization due to KCHIP. However, with the suspension of the program, review of records revealed that all facilities experienced a significant reduction in out-patient loads as there was gradual decline in healthcare utilization in the clinics record (Fig. 2). No appreciable effect was seen on in-patient visits (Fig. 3). Out of those that reported reduction in service provision, a facility manager said; "At present, just about 5% of those previously 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 onequarter 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 maleheaded 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 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 former enrollees still preferred using the KCHIP health facilities and they reverted almost ubiquitously to OOP payments. At the same time, out-patient healthcare consumption decreased substantially, with a large proportion of former enrollees not being able to afford healthcare services. Belonging to some form of financial/social group proved beneficial in the short term as a coping mechanism.
Social capital built through KCHIP between former enrollees and clinics helped alleviate part of the financial burden for the former enrollees, but not for the facilities. Enrollees with the highest probability of suffering adverse consequences of the program suspension were households in the lower social quintiles, living in rural communities and those reporting recent acute illness. Private health facilities suffered more consequences of the program suspension than public facilities in terms of reduced financial inflow sequel to change in the revenue and resources.
These observations point to the need of designing effective transition processes from community-based health insurance to State insurance in other Nigerian states.

Declarations
Ethics approval and consent to participate: Written permissions were obtained from the ethics committee of the Kwara State Ministry of Health, Ilorin, Nigeria.
Informed consent was obtained from the participants Confidentiality of the participants' and health facilities' information were maintained.

Figure 2
Out-patients' visits by month for the year 2016 across the public and private health facilities In-patient visits by month for the year 2016 across public and private health facilities.