International Journal of Health Policy and Management

International Journal of Health Policy and Management

Predictors of Enrolment in the National Health Insurance Scheme Among Women of Reproductive Age in Nigeria

Document Type : Original Article

Authors
Bolaji Samson Aregbeshola 1
Samina Mohsin Khan 2
1 Department of Community Health & Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria
2 Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
10.15171/ijhpm.2018.68
Abstract
Background
Despite the implementation of the National Health Insurance Scheme (NHIS) since 2005 in Nigeria, the level of health insurance coverage remains low. The study aims to examine the predictors of enrolment in the NHIS among women of reproductive age in Nigeria.
 
Methods
Secondary data from the 2013 Nigeria Demographic and Health Survey (NDHS) were utilized to examine factors influencing enrolment in the NHIS among women of reproductive age (n = 38 948) in Nigeria. Demographic and socio-economic characteristics of women were determined using univariate, bivariate and multivariate analyses. Data analysis was performed using STATA version 12 software.
 
Results
We found that 97.9% of women were not covered by health insurance. Multivariate analysis indicated that factors such as age, education, geo-political zone, socio-economic status (SES), and employment status were significant predictors of enrolment in the NHIS among women of reproductive age.
 
Conclusion
This study concludes that health insurance coverage among women of reproductive age in Nigeria is very low. Additionally, demographic and socio-economic factors were associated with enrolment in the NHIS among women. Therefore, policy-makers need to establish a tax-based health financing mechanism targeted at women who are young, uneducated, from poorest households, unemployed and working in the informal sector of the economy. Extending health insurance coverage to women from poor households and those who work in the informal sector through a tax-financed non-contributory health insurance scheme would accelerate progress towards universal health coverage (UHC).
Keywords
National Health Insurance
Enrolment
Women
Universal Health Coverage
Nigeria
Subjects
  1. International Labour Office. Women and men in the informal economy: A statistical picture. 3rd ed. Geneva: International Labour Office; 2018.
  2. Wolfe R. Expanding health coverage for those outside the formal sector. 2013. http://resyst.lshtm.ac.uk/sites/resyst.lshtm.ac.uk/files/docs/reseources/Financial%20protection%20brief.pdf. Accessed February 8, 2018.
  3. Kazungu JS, Barasa EW. Examining levels, distribution and correlates of health insurance coverage in Kenya. Trop Med Int Health. 2017;22(9):1175-1185. doi:10.1111/tmi.12912
  4. Smith KV, Sulzbach S. Community-based health insurance and access to maternal health services: evidence from three West African countries. Soc Sci Med. 2008;66(12):2460-2473. doi:10.1016/j.socscimed.2008.01.044
  5. Wang H, Yip W, Zhang L, Hsiao WC. The impact of rural mutual health care on health status: evaluation of a social experiment in rural China. Health Econ. 2009;18 Suppl 2:S65-82. doi:10.1002/hec.1465
  6. Kozhimannil KB, Valera MR, Adams AS, Ross-Degnan D. The population-level impacts of a national health insurance program and franchise midwife clinics on achievement of prenatal and delivery care standards in the Philippines. Health Policy. 2009;92(1):55-64. doi:10.1016/j.healthpol.2009.02.009
  7. Mensah J, Oppong JR, Schmidt CM. Ghana's National Health Insurance Scheme in the context of the health MDGs: an empirical evaluation using propensity score matching. Health Econ. 2010;19 Suppl:95-106. doi:10.1002/hec.1633
  8. Escobar ML, Griffin CC, Shaw RP. The impact of health insurance in low- and middle-income countries. Washington, DC: Brookings Institution Press; 2010.
  9. Hong R, Ayad M, Ngabo F. Being insured improves safe delivery practices in Rwanda. J Community Health. 2011;36(5):779-784. doi:10.1007/s10900-011-9376-4
  10. Dong H, Escobar ML, Griffin CC, Shaw RP. The impact of health insurance in low-and-middle-income countries. Journal of International Development. 2012;24:529-530.
  11. Nguyen HT, Hatt L, Islam M, et al. Encouraging maternal health service utilization: an evaluation of the Bangladesh voucher program. Soc Sci Med. 2012;74(7):989-996. doi:10.1016/j.socscimed.2011.11.030
  12. Witter S, Garshong B. Something old or something new? Social health insurance in Ghana. BMC Int Health Hum Rights. 2009;9:20. doi:10.1186/1472-698x-9-20
  13. World Health Organization. Sustainable health financing, universal coverage and social health insurance. Geneva: World Health Organization; 2005.
  14. United Nations. Transforming our world: The 2030 agenda for sustainable development. 2015. https://sustainabledevelopment.un.org/post2015/transformingourworld/publication. Accessed February 8, 2018.
  15. Aregbeshola BS. Enhancing Political Will for Universal Health Coverage in Nigeria. MEDICC Rev. 2017;19(1):42-46. doi:10.1590/medicc.2017.190100010
  16. World Health Organization, World Bank. Tracking universal health coverage: 2017 Global Monitoring Report. Switzerland: World Health Organization and World Bank; 2017.
  17. World Health Organization. World Health Statistics 2018: Monitoring health for the SDGs. Geneva: World Health Organization; 2018.
  18. Onoka CA, Onwujekwe OE, Uzochukwu BS, Ezumah NN. Promoting universal financial protection: constraints and enabling factors in scaling-up coverage with social health insurance in Nigeria. Health Res Policy Syst. 2013;11:20. doi:10.1186/1478-4505-11-20
  19. Okebukola PO, Brieger WR. Providing Universal Health Insurance Coverage in Nigeria. Int Q Community Health Educ. 2016;36(4):241-246. doi:10.1177/0272684x16657451
  20. McIntyre D, Ranson MK, Aulakh BK, Honda A. Promoting universal financial protection: evidence from seven low- and middle-income countries on factors facilitating or hindering progress. Health Res Policy Syst. 2013;11:36. doi:10.1186/1478-4505-11-36
  21. Jutting JP. Do Community-based health insurance schemes improve poor people’s access to health care? Evidence from rural Senegal. World Dev. 2004;32(2):273-288. doi:10.1016/j.worlddev.2003.10.001
  22. Kirigia JM, Sambo LG, Nganda B, Mwabu GM, Chatora R, Mwase T. Determinants of health insurance ownership among South African women. BMC Health Serv Res. 2005;5(1):17. doi:10.1186/1472-6963-5-17
  23. De Allegri M, Kouyate B, Becher H, et al. Understanding enrolment in community health insurance in sub-Saharan Africa: a population-based case-control study in rural Burkina Faso. Bull World Health Organ. 2006;84(11):852-858.
  24. Mathauer I, Schmidt JO, Wenyaa M. Extending social health insurance to the informal sector in Kenya. An assessment of factors affecting demand. Int J Health Plann Manage. 2008;23(1):51-68. doi:10.1002/hpm.914
  25. Onwujekwe O, Okereke E, Onoka C, Uzochukwu B, Kirigia J, Petu A. Willingness to pay for community-based health insurance in Nigeria: do economic status and place of residence matter? Health Policy Plan. 2010;25(2):155-161. doi:10.1093/heapol/czp046
  26. Kiplagat I, Muriithi M, Kioko U. Determinants of health insurance choice in Kenya. Eur Sci J. 2013;9(13):452-468.
  27. Jehu-Appiah C, Aryeetey G, Spaan E, de Hoop T, Agyepong I, Baltussen R. Equity aspects of the National Health Insurance Scheme in Ghana: Who is enrolling, who is not and why? Soc Sci Med. 2011;72(2):157-165. doi:10.1016/j.socscimed.2010.10.025
  28. Dixon J, Tenkorang EY, Luginaah I. Ghana's National Health Insurance Scheme: helping the poor or leaving them behind? Environ Plann C Gov Policy. 2011;29(6):1102-1115. doi:10.1068/c1119r
  29. Dixon J, Luginaah I, Mkandawire P. The National Health Insurance Scheme in Ghana's Upper West Region: a gendered perspective of insurance acquisition in a resource-poor setting. Soc Sci Med. 2014;122:103-112. doi:10.1016/j.socscimed.2014.10.028
  30. Kimani JK, Ettarh R, Kyobutungi C, Mberu B, Muindi K. Determinants for participation in a public health insurance program among residents of urban slums in Nairobi, Kenya: results from a cross-sectional survey. BMC Health Serv Res. 2012;12:66. doi:10.1186/1472-6963-12-66
  31. Kimani JK, Ettarh R, Warren C, Bellows B. Determinants of health insurance ownership among women in Kenya: evidence from the 2008-09 Kenya demographic and health survey. Int J Equity Health. 2014;13:27. doi:10.1186/1475-9276-13-27
  32. Akazili J, Welaga P, Bawah A, et al. Is Ghana's pro-poor health insurance scheme really for the poor? Evidence from Northern Ghana. BMC Health Serv Res. 2014;14:637. doi:10.1186/s12913-014-0637-7
  33. Bonfrer I, Breebaart L, Van de Poel E. The Effects of Ghana's National Health Insurance Scheme on Maternal and Infant Health Care Utilization. PLoS One. 2016;11(11):e0165623. doi:10.1371/journal.pone.0165623
  34. Kusi A, Fenny AP, Arhinful DK, Asante FA, Parmar D. Determinants of enrollment in the NHIS for women in Ghana. Int J Soc Econ. 2017. doi:10.1108/IJSE-10-2016-0291
  35. Mulenga JN, Bwalya BB, Gebremeskel Y. Demographic and Socio-economic determinants of maternal health insurance coverage in Zambia. Epidemiol Biostat Public Health. 2017;14(1):e12094-1- e12094-9. doi:10.2427/12094
  36. Boateng D, Awunyor-Vitor D. Health insurance in Ghana: evaluation of policy holders' perceptions and factors influencing policy renewal in the Volta region. Int J Equity Health. 2013;12:50. doi:10.1186/1475-9276-12-50
  37. Kumi-Kyereme A, Amo-Adjei J. Effects of spatial location and household wealth on health insurance subscription among women in Ghana. BMC Health Serv Res. 2013;13:221. doi:10.1186/1472-6963-13-221
  38. Sarpong N, Loag W, Fobil J, et al. National health insurance coverage and socio-economic status in a rural district of Ghana. Trop Med Int Health. 2010;15(2):191-197. doi:10.1111/j.1365-3156.2009.02439.x
  39. Wang W, Temsah G, Mallick L. Health insurance coverage and its impact on maternal health care utilization in low- and middle-income countries. DHS Analytical Studies No. 45. Rockville, Maryland, USA: ICF International; 2014.
  40. Chankova S, Sulzbach S, Diop F. Impact of mutual health organizations: evidence from West Africa. Health Policy Plan. 2008;23(4):264-276. doi:10.1093/heapol/czn011
  41. Basaza R, Criel B, Van der Stuyft P. Community health insurance in Uganda: why does enrolment remain low? A view from beneath. Health Policy. 2008;87(2):172-184. doi:10.1016/j.healthpol.2007.12.008
  42. Dong H, Gbangou A, De Allegri M, Pokhrel S, Sauerborn R. The differences in characteristics between health-care users and non-users: implication for introducing community-based health insurance in Burkina Faso. Eur J Health Econ. 2008;9(1):41-50. doi:10.1007/s10198-006-0031-4
  43. National Health Insurance Scheme. National health insurance scheme decree No 35 of 1999. http://www.nigeria-law.org/National%20Health%20Insurance%20Scheme%20Decree.htm. Accessed February 8, 2018.
  44. Giedion U, Alfonso EA, Diaz Y. The impact of universal coverage schemes in the developing world: a review of the existing evidence. Washington, DC: World Bank; 2013. UNICO Studies Series 25.
  45. World Health Organization. Nigeria: Factsheets of health statistics 2016.  http://www.aho.afro.who.int/profiles_information/images/3/3b/Nigeria-Statistical_Factsheet.pdf Accessed March 30, 2018.
  46. McIntyre D, Thiede M, Dahlgren G, Whitehead M. What are the economic consequences for households of illness and of paying for health care in low- and middle-income country contexts? Soc Sci Med. 2006;62(4):858-865. doi:10.1016/j.socscimed.2005.07.001
  47. Aregbeshola BS, Khan SM. Out-of-Pocket Payments, Catastrophic Health Expenditure and Poverty Among Households in Nigeria 2010. Int J Health Policy Manag. 2018; forthcoming. doi:10.15171/ijhpm.2018.19
  48. Wagstaff A. Health insurance for the poor: initial impacts of Vietnam’s health care fund for the poor. Policy Research Working Paper, 4134. World Bank; 2007.
  49. Aggarwal A. Impact evaluation of India's 'Yeshasvini' community-based health insurance programme. Health Econ. 2010;19 Suppl:5-35. doi:10.1002/hec.1605
  50. Wagner AK, Graves AJ, Reiss SK, Lecates R, Zhang F, Ross-Degnan D. Access to care and medicines, burden of health care expenditures, and risk protection: results from the World Health Survey. Health Policy. 2011;100(2-3):151-158. doi:10.1016/j.healthpol.2010.08.004
  51. Odeyemi IA. Community-based health insurance programmes and the National Health Insurance Scheme of Nigeria: challenges to uptake and integration. Int J Equity Health. 2014;13:20. doi:10.1186/1475-9276-13-20
  52. Onoka CA, Hanson K, Mills A. Growth of health maintenance organisations in Nigeria and the potential for a role in promoting universal coverage efforts. Soc Sci Med. 2016;162:11-20. doi:10.1016/j.socscimed.2016.06.018
  53. National Population Commission (NPC) [Nigeria], ICF Macro. Nigeria Demographic and Health Survey 2013. Abuja, Nigeria: National Population Commission and ICF Macro; 2014.
  54. Aday LA, Andersen R. A framework for the study of access to medical care. Health Serv Res. 1974;9(3):208-220.
  55. Grossman M. On the Concept of Health Capital and the Demand for Health. J Polit Econ. 1972;80(2):223-255. doi:10.1086/259880
  56. Vyas S, Kumaranayake L. Constructing socio-economic status indices: how to use principal components analysis. Health Policy Plan. 2006;21(6):459-468. doi:10.1093/heapol/czl029
  57. Marquis MS, Holmer MR. Alternative Models of Choice Under Uncertainty and Demand for Health Insurance. Rev Econ Stat. 1996;78(3):421-427. doi:10.2307/2109789
  58. Tangcharoensathien V, Patcharanarumol W, Ir P, et al. Health-financing reforms in southeast Asia: challenges in achieving universal coverage. Lancet. 2011;377(9768):863-873. doi:10.1016/s0140-6736(10)61890-9
  59. Tangcharoensathien V, Pitayarangsarit S, Patcharanarumol W, et al. Promoting universal financial protection: how the Thai universal coverage scheme was designed to ensure equity. Health Res Policy Syst. 2013;11:25. doi:10.1186/1478-4505-11-25
  60. Okungu V, Chuma J, Mulupi S, McIntyre D. Extending coverage to informal sector populations in Kenya: design preferences and implications for financing policy. BMC Health Serv Res. 2018;18(1):13. doi:10.1186/s12913-017-2805-z
  61. Cotlear D, Nagpal S, Smith O, Tandon A, Cortez R. Going Universal: How 24 countries are implementing universal health coverage reforms from the bottom up. Washington, DC: World Bank; 2016.
International Journal of Health Policy and Management
Volume 7, Issue 11
November 2018
Pages 1015-1023

  • Received Date 07 March 2018
  • Revised Date 20 July 2018
  • Accepted Date 21 July 2018
  • First Published Date 01 November 2018
  • Published Date 01 November 2018