This study assessed the effects of the suspension of a community-based health insurance programme in Kwara State, Nigeria. This suspension was due to the restructuring and repositioning of the scheme for a major Government policy change to herald a state-wide health insurance program. This, therefore, necessitated an unusual 'reverse intervention' evaluation of community-based health insurance. This we carried out using a mixed-method to study both the former enrollees in KCHIP and the participating healthcare facilities.
Firstly, this study reported 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 and perceived quality of care. The quality upgrades and periodic training drive at the KCHIP facilities before the programme suspension were most likely contributory factors to the quality of care observed by the enrollees. Also, other quality improvement interventions executed by KCHIP included capacity building on protocol and guidelines for treatments, records, laboratory, drug storage and infrastructure (10,11). Therefore, this improved the quality of care and standard of practice in the KCHIP facilities with basically a few alternative options of similar medical quality available for enrollees in the State. The trust and the continuing usage of the KCHIP facilities reported by the enrollees after the suspension showed the propensity of community-based health insurance, when combined with quality improvement of medical services, to remove barriers to healthcare utilization (4). The trust and cordial relationship are shown by the former enrollees to KCHIP facilities can be harnessed for the high uptake of the incoming state-wide health insurance scheme.
This study also demonstrated that three-quarters of the former KCHIP enrollees reverted to OOP payment after suspension of the program. Because 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 the build-up of social benefits from the KCHIP, though at a certain cost to the healthcare providers. The high rate of reversal to OOP endangered and eroded 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 suspension, as well as the general economic recession in Nigeria, were mentioned as the most important perceived causes. The economic recession has been reported elsewhere to cause a reduction in individual expenditure and health insurance consumption (16). 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. Enrollees also reported receiving support from financial or social groups in the form of “ajo” thrifts and; religious, community and social cooperative groups as a form of coping for the unexpected healthcare cost after the suspension. These were beneficial to individuals who required funds for sickness. Such financial and social groups are effective coping strategies in terms of improved household income (17). This underscores the potentials of local thrifts and cooperative groups in financing the health insurance enrollment fees in Nigeria communities.
The male enrollees living in rural communities reported more difficulties paying for healthcare services after the programme 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 reflects 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.
A previous study in Kwara State on spending for non-communicable chronic disease (NCCD) reported health expenditures relative to the 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). This finding to the state-wide scheme implies that the low socio-economic group are at more risk of financial constraint. They should have enrollment fees subsidized or paid for through a government social scheme. Enrollees who experienced an acute illness or injury in the preceding 12 months before the suspension of enrollment had increase odds of being financially constrained in the ability to pay after the suspension. Several Nigerian studies (22) also reported an increased risk of incurring catastrophic health expenditures for household members with non-chronic illnesses. This finding implied that the enrollees with acute illnesses are more likely to be unprepared and could suffer more financial constraints paying for healthcare services without health insurance scheme.
While there were no serious consequences concerning the range of service provision, a significant reduction in patient load in (almost) all of the KCHIP facilities were observed. However, there were slight spikes on patient load around the wet months of the year, which supported seasonal patterns of health-seeking behavior in Nigeria. This is 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 these effects. Some public health facilities even reported an increase in the revenue generation because of the removal of insurance programme users charge restrictions on the direct billing of the patients. This is also possibly due to some shift of private patients towards the public sector since some services were free in public health facilities. Private health facilities disproportionately suffered a reduction in staff strength, motivation and productivity. This resulted in the downsizing of staff in many of these facilities. Also, we observed a downward trend in drug purchase among the private health facilities, which remained unchanged in public facilities that kept benefiting from the 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. These finding revealed that though the private facilities enjoyed the trust of the enrollees before the suspension, they were unable to cope with service provisions and staff retention after suspension like the public facilities who enjoyed funding from the government.
In the literature, suspending an impactful health insurance programme is an unusual 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 programme due to inability to sustain the exclusive funding of the programme 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 and uncertainty regarding payment of Qataris' medical bills and UHC. The suspension of the Qatari health insurance programme adversely affected hospitals, health centers and patients, which caused a negative outcry among the population (23). Similar observations are made in Kwara concerning 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 programs to a larger State-owned insurance programme 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). A 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 Value Added Tax (VAT) such as in Ghana (24).
This paper demonstrates that temporary suspension of health insurance in the absence of transitional measures has consequences for enrollees and healthcare providers. It also provides opportunities to learn lessons. For example, it was learnt that transition periods can leverage 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 the 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. All these should be harnessed for a sustainable and effective health insurance scheme in Kwara State, Nigeria