Healthcare clinic and pharmacy chains in Kenya and Nigeria: A qualitative exploration of the opportunities and risks they present for healthcare regulatory systems

BACKGROUND

Regulating fragmented healthcare markets is a major challenge in low- and middle-income countries. Although a recent transformation towards consolidation could improve regulatory efficiency, there are concerns over risks to client safety and market functioning. We investigated market consolidation through the emergence of clinic and pharmacy chains in Kenya and Nigeria and explored resultant regulatory opportunities and risks.

METHODS

The study was conducted in Nairobi Kenya and Abuja Nigeria. Data were collected through document reviews and 26 interviews with chain operators, professional associations and regulators between September and December 2018. A thematic analysis was conducted.

RESULTS

We characterised two broad types of chains: organic chains that started as single business locations and expanded gradually, and investor-driven chains that expanded rapidly following external capital injection. In both countries, chains and independents were regulated similarly, with regulators failing to both capitalize on opportunities and guard against risks. For instance, chains' brand visibility and centralised management systems made them easier to regulate and more suitable for self-regulation. On the other hand, chains were perceived to pose the risks of market dominance, commercialisation of healthcare, and regulatory capture.

CONCLUSION

As healthcare chains expand, regulators should build on opportunities presented and guard against emerging risks.

Equity of resource flows for reproductive, maternal, newborn, and child health: are those most in need being left behind?

Although equity has improved in recent years, donors and country governments still need to improve the amount and targeting of funding for reproductive, maternal, and child health, say Melisa Martinez-Alvarez and colleagues

Targeting the last polio sanctuaries with Directly Observed Oral Polio Vaccination (DOPV) in northern Nigeria, (2014-2016)

Background

The declaration of poliomyelitis eradication as a programmatic emergency for global public health by the 65th World Health Assembly in 2012 necessitated innovations and strategies to achieve results. Review of the confirmed polio cases in 2013 showed that most of the cases were from non-compliant households, where parents connived with vaccinators to finger mark the children without actually vaccinating the children with oral polio vaccine or children were absent from home at the time of the visit of vaccinators.

Methods

We used pre-post design to quantify the outcomes of directly observed vaccination in 90 local government areas from 12 northern Nigeria states at very high risk of polio transmission.

The strategy is an intervention, vaccinating children under the direct supervision of an independent supervisor to ensure compliance. Attractive incentives (pluses) were used to make parents willingly submit their children for vaccination or directly attract children to the vaccination teams or post as part of this strategy.

Results

There was a steady increase in population immunity in all the 90 DOPV implementing LGAs since the introduction of DOPV in 2013. The number of states in which > 90% of children received > 4 OPV doses increased from 7 in 2013 to 11 states by July 2016.

Yobe state reported the highest proportional increase from 75 to 99% by July 2016 (22% increase), while Kano state reported 17% increase, from 82 to 99% by July 2016.

Conclusion

Directly observed polio vaccination strategy improved uptake of polio vaccines and population immunity in high-risk areas for polio transmission.

AVADAR (Auto-Visual AFP Detection and Reporting): demonstration of a novel SMS-based smartphone application to improve acute flaccid paralysis (AFP) surveillance in Nigeria

Background

Eradication of polio requires that the acute flaccid paralysis (AFP) surveillance system is sensitive enough to detect all cases of AFP, and that such cases are promptly reported and investigated by disease surveillance personnel. When individuals, particularly community informants, are unaware of how to properly detect AFP cases or of the appropriate reporting process, they are unable to provide important feedback to the surveillance network within a country.

Methods

We tested a new SMS-based smartphone application (App) that enhances the detection and reporting of AFP cases to improve the quality of AFP surveillance. Nicknamed Auto-Visual AFP Detection and Reporting (AVADAR), the App creates a scenario where the AFP surveillance network is not dependent on a limited number of priority reporting sites. Being installed on the smartphones of multiple health workers (HWs) and community health informants (CHIs) makes the App an integral part of the detection and reporting system.

Results

Results from two phases of tests conducted in Nigeria point to the effectiveness of the App in the surveillance of AFP.

Conclusion

We posit that appropriate use of the App can soon bring about a worldwide eradication of poliomyelitis.

Environmental, economic and socio-cultural risk factors of recurrent seasonal epidemics of cerebrospinal meningitis in Kebbi state, northwestern Nigeria: a qualitative approach

BACKGROUND

Kebbi State remains the epicentre of the seasonal epidemic meningitis in northwestern Nigeria despite interventions. In this setting, no previous study has been conducted to understand the risk factors of the recurrent meningitis epidemics using qualitative approach. Consequently, this study intends to explore and better understand the environmental, economic and socio-cultural factors of recurrent seasonal epidemic meninigitis using a qualitative approach.

METHODS

We conducted in-depth interview (40 IDIs) and focus group discussions (6 FGDs) in two local government areas (LGAs) in Kebbi State, Northwestern Nigeria to understand the environmental, economic and socio-cultural factors of recurrent meningitis outbreaks. Routine surveillance data were used to guide the selection of settlements, wards and local government areas based on the frequency of re-occurrences and magnitude of the outbreaks.

RESULTS

The discussions revealed certain elements capable of potentiating the recurrence of seasonal meningitis epidemics. These are environmental issues, such as poorly-designed built environment, crowded sleeping and poorly ventilated rooms, dry and dusty weather condition. Other elements were economic challenges, such as poor household living conditions, neighbourhood deprivation, and socio-cultural elements, such as poor healthcare seeking behaviour, social mixing patterns, inadequate vaccination and vaccine hesitancy.

CONCLUSION

As suggested by participants, there are potential environmental, socio-cultural and economic factors in the study area that might have been driving recurrent epidemics of cerebrospinal meningitis. In a bid to addressing this perennial challenge, governments at various levels supported by health development partners such as the World Health Organisation (WHO), United Nation Habitat, and United National Development Programme can use the findings of this study to design policies and programmes targeting these factors towards complementing other preventive and control strategies.

Routine immunization community surveys as a tool for guiding program implementation in Kaduna state, Nigeria 2015-2016

Background

Routine childhood immunization remains an important strategy for achieving polio eradication and maintaining a polio-free world. To address gaps in reported administrative coverage data, community surveys were conducted to verify coverage, and guide strategic interventions for improved coverage.

Methods

We reviewed the conduct of community surveys by World Health Organization (WHO) field volunteers deployed as part of the surge capacity to Kaduna state and the use of survey results between July 2015 and June 2016. Monthly and quarterly collation and use of these data to guide the deployment of various interventions aimed at strengthening routine immunization in the state.

Results

Over 97,000 children aged 0–11 months were surveyed by 138 field volunteers across 237 of the 255 wards in Kaduna state. Fully or appropriately immunized children increased from 67% in the fourth quarter of 2015 to 76% by the end of the second quarter of 2016. Within the period reviewed, the number of local government areas with < 80% coverage reduced from eight to zero.

Conclusions

The routine conduct of community surveys by volunteers to inform interventions has shown an improvement in the vaccination status of children 0–11 months in Kaduna state and remains a useful tool in addressing administrative data quality issues.

Examining the Financial Feasibility of Using a New Special Health Fund to Provide Universal Coverage for a Basic Maternal and Child Health Benefit Package in Nigeria

Background: A special health fund was established in Nigeria in 2014 and is known as the Basic Health Care Provision Fund (BHCPF). The fund is equivalent to at least 1% of the Consolidated Revenue of the Federation. The BHCPF will provide additional revenue to fund primary healthcare services and help Nigeria to achieve universal health coverage (UHC). This fund is to be matched with counterpart funds from states and local government areas (LGAs), and is expected to provide at least a basic benefit health package that will cover maternal and child health (MCH) services for pregnant women and under-five children. Objective: To determine the financial feasibility of using the BHCPF to provide a minimum benefit package to cover all pregnant women and under-five children in Nigeria. Methods: The study focused on three states in Nigeria: Imo, Kaduna, and Niger. The feasibility analysis was performed using 3 scenarios but the main analysis was Scenario 1, which was based on the funding of drugs and consumables only. All the costs and revenues were in 2015 levels. The standard costs of a minimum benefit package for the different states were multiplied by the number of target beneficiaries to determine the amount required for the year. Financial feasibility is determined by the excess or otherwise of revenue over costs. Findings: It was found that in the best case funding scenario of using 95% of the CRF with 25% counterpart funding from states and LGAs, the entire available funds were not adequate to cover the benefit package for all the pregnant women and under-five children in the three states. The funds were also inadequate to cover the target beneficiaries that live below the poverty line in two of the states. Conclusion: The BHCPF is a good step toward providing essential MCH services, but the current level of funding will not assure UHC for all the target beneficiaries. However, the available funds should be used immediately to target priority mothers and children such as vulnerable groups, whilst sourcing for additional funds to ensure universal coverage of MCH services.

Reliability of Self-Reported Mobile Phone Ownership in Rural North-Central Nigeria: Cross-Sectional Study

Background

mHealth practitioners seek to leverage the ubiquity of the mobile phone to increase the impact and robustness of their interventions, particularly in resource-limited settings. However, data on the reliability of self-reported mobile phone access is minimal.

Objective

We sought to ascertain the reliability of self-reported ownership of and access to mobile phones among a population of rural dwellers in north-central Nigeria.

Methods

We contacted participants in a community-based HIV testing program by phone to determine actual as opposed to self-reported mobile phone access. A phone script was designed to conduct these calls and descriptive analyses conducted on the findings.

Results

We dialed 349 numbers: 110 (31.5%) were answered by participants who self-reported ownership of the mobile phone; 123 (35.2%) of the phone numbers did not ring at all; 28 (8.0%) rang but were not answered; and 88 (25.2%) were answered by someone other than the participant. We reached a higher proportion of male participants (68/133, 51.1%) than female participants (42/216, 19.4%; P<.001).

Conclusions

Self-reported access to mobile phones in rural and low-income areas in north-central Nigeria is higher than actual access. This has implications for mHealth programming, particularly for women’s health. mHealth program implementers and researchers need to be cognizant of the low reliability of self-reported mobile phone access. These observations should therefore affect sample-size calculations and, where possible, alternative means of reaching research participants and program beneficiaries should be established.

A Patient-Held Smartcard With a Unique Identifier and an mHealth Platform to Improve the Availability of Prenatal Test Results in Rural Nigeria: Demonstration Study

BACKGROUND

Community-based strategies to test for HIV, hepatitis B virus (HBV), and sickle cell disease (SCD) have expanded opportunities to increase the proportion of pregnant women who are aware of their diagnosis. In order to use this information to implement evidence-based interventions, these results have to be available to skilled health providers at the point of delivery. Most electronic health platforms are dependent on the availability of reliable Internet connectivity and, thus, have limited use in many rural and resource-limited settings.

OBJECTIVE

Here we describe our work on the development and deployment of an integrated mHealth platform that is able to capture medical information, including test results, and encrypt it into a patient-held smartcard that can be read at the point of delivery without the need for an Internet connection.

METHODS

We engaged a team of implementation scientists, public health experts, and information technology specialists in a requirement-gathering process to inform the design of a prototype for a platform that uses smartcard technology, database deployment, and mobile phone app development. Key design decisions focused on usability, scalability, and security.

RESULTS

We successfully designed an integrated mHealth platform and deployed it in 4 health facilities across Benue State, Nigeria. We developed the Vitira Health platform to store test results of HIV, HBV, and SCD in a database, and securely encrypt the results on a Quick Response code embedded on a smartcard. We used a mobile app to read the contents on the smartcard without the need for Internet connectivity.

CONCLUSIONS

Our findings indicate that it is possible to develop a patient-held smartcard and an mHealth platform that contains vital health information that can be read at the point of delivery using a mobile phone-based app without an Internet connection.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03027258; https://clinicaltrials.gov/ct2/show/NCT03027258 (Archived by WebCite at http://www.webcitation.org/6owR2D0kE).

Male partner involvement on initiation and sustainment of exclusive breastfeeding among HIV-infected post-partum women: Study protocol for a randomized controlled trial

Exclusive Breastfeeding (EBF) among human immunodeficiency virus (HIV)-infected mothers is known to be associated with a sustained and significant reduction in HIV transmission and has the potential to reduce infant and under-five mortality. Research shows that EBF is not common in many HIV-endemic, resource-limited settings despite recommendations by the World Health Organization. Although evidence abounds that male partner involvement increases HIV testing and uptake and retention of prevention of mother-to-child transmission interventions, few studies have evaluated the impact of male partners' involvement and decision-making on initiation, maintenance, and sustainment of EBF. We propose a comparative effectiveness trial of Men's Club as intervention group compared to the control group on initiation and sustainment of EBF. Men's Club will provide male partners of HIV-infected pregnant women one 5-hr interactive educational intervention to increase knowledge on EBF and explore barriers and facilitators of EBF and support. Additionally, participating male partners in the Men's Club as intervention group will receive weekly text message reminders during the first 6-week post-natal period to improve initiation and sustainment of EBF. Participants in the Men's Club as control group will receive only educational pamphlets. Primary outcomes are the differences in the rates of initiation and sustainment of EBF at 6 months between the two groups. Secondary outcomes are differences in male partner knowledge of infant feeding options and the intent to support EBF in the two groups. Understanding the role and impact of male partners on the EBF decision-making process will inform the development of effective and sustainable evidence-based interventions to support the initiation and sustainment of EBF.

An mHealth Framework to Improve Birth Outcomes in Benue State, Nigeria: A Study Protocol

BACKGROUND

The unprecedented coverage of mobile technology across the globe has led to an increase in the use of mobile health apps and related strategies to make health information available at the point of care. These strategies have the potential to improve birth outcomes, but are limited by the availability of Internet services, especially in resource-limited settings such as Nigeria.

OBJECTIVE

Our primary objective is to determine the feasibility of developing an integrated mobile health platform that is able to collect data from community-based programs, embed collected data into a smart card, and read the smart card using a mobile phone-based app without the need for Internet access. Our secondary objectives are to determine (1) the acceptability of the smart card among pregnant women and (2) the usability of the smart card by pregnant women and health facilities in rural Nigeria.

METHODS

We will leverage existing technology to develop a platform that integrates a database, smart card technology, and a mobile phone-based app to read the smart cards. We will recruit 300 pregnant women with one of the three conditions-HIV, hepatitis B virus infection, and sickle cell trait or disease-and four health facilities in their community. We will use Glasgow's Reach, Effectiveness, Adoption, Implementation, and Maintenance framework as a guide to assess the implementation, acceptability, and usability of the mHealth platform.

RESULTS

We have recruited four health facilities and 300 pregnant women with at least one of the eligible conditions. Over the course of 3 months, we will complete the development of the mobile health platform and each participant will be offered a smart card; staff in each health facility will receive training on the use of the mobile health platform.

CONCLUSIONS

Findings from this study could offer a new approach to making health data from pregnant women available at the point of delivery without the need for an Internet connection. This would allow clinicians to implement evidence-based interventions in real time to improve health outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03027258; https://clinicaltrials.gov/ct2/show/NCT03027258 (Archived by WebCite at http://www.webcitation.org/6owR2D0kE).

Building Sustainable Local Capacity for Global Health Research in West Africa

BACKGROUND

Global health research in resource-limited countries has been largely sponsored and led by foreign institutions. Thus, these countries' training capacity and productivity in global health research is limited. Local participation at all levels of global health knowledge generation promotes equitable access to evidence-based solutions. Additionally, leadership inclusive of competent local professionals promotes best outcomes for local contextualization and implementation of successful global health solutions. Among the sub-Saharan African regions, West Africa in particular lags in research infrastructure, productivity, and impact in global health research.

OBJECTIVE

In this paper, experts discuss strategies for scaling up West Africa's participation in global health evidence generation using examples from Ghana and Nigeria.

METHODS

We conducted an online and professional network search to identify grants awarded for global health research and research education in Ghana and Nigeria. Principal investigators, global health educators, and representatives of funding institutions were invited to add their knowledge and expertise with regard to strengthening research capacity in West Africa.

FINDINGS

While there has been some progress in obtaining foreign funding, foreign institutions still dominate local research. Local research funding opportunities in the 2 countries were found to be insufficient, disjointed, poorly sustained, and inadequately publicized, indicating weak infrastructure. As a result, research training programs produce graduates who ultimately fail to launch independent investigator careers because of lack of mentoring and poor infrastructural support.

CONCLUSIONS

Research funding and training opportunities in Ghana and Nigeria remain inadequate.

RECOMMENDATIONS

We recommend systems-level changes in mentoring, collaboration, and funding to drive the global health research agenda in these countries. Additionally, research training programs should be evaluated not only by numbers of individuals graduated but also by numbers of independent investigators and grants funded. Through equitable collaborations, infrastructure, and mentoring, West Africa can match the rest of Africa in impactful global health research.

Viewing health expenditures, payment and coping mechanisms with an equity lens in Nigeria

BACKGROUND

This paper examines socio-economic and geographic differences in payment and payment coping mechanisms for health services in southeast Nigeria. It shows the extent to which the poor and rural dwellers disproportionally bear the burden of health care costs and offers policy recommendations for improvements.

METHODS

Questionnaires were used to collect data from 3071 randomly selected households in six communities in southeast Nigeria using a four week recall. The sample was divided into quintiles (Q1-Q5) using a socio-economic status (SES) index as well as into geographic groups (rural, peri-urban and urban). Tabulations and logistic regression were used to determine the relationships between payment and payment coping mechanisms and key independent variables. Q1/Q5 and rural/urban ratios were the measures of equity.

RESULTS

Most of the respondents used out-of-pocket spending (OOPS) and own money to pay for healthcare. There was statistically significant geographic differences in the use of own money to pay for health services indicating more use among rural dwellers. Logistic regression showed statistically significant geographic differences in the use of both OOPS and own money when controlling for the effects of potential cofounders.

CONCLUSIONS

This study shows statistically significant geographic differences in the use of OOPS and own money to pay for health services. Though the SES differences were not statistically significant, they showed high equity ratios indicating more use among poor and rural dwellers. The high expenditure incurred on drugs alone highlights the need for expediting pro-poor interventions like exemptions and waivers aimed at improving access to health care for the vulnerable poor and rural dwellers.

Constraints to universal coverage: inequities in health service use and expenditures for different health conditions and providers

BACKGROUND

There is need for new information about the socio-economic and geographic differences in health seeking and expenditures on many health conditions, so to help to design interventions that will reduce inequity in utilisation of healthcare services and ensure universal coverage.

OBJECTIVES

The paper contributes additional knowledge about health seeking and economic burden of different health conditions. It also shows the level of healthcare payments in public and private sector and their distribution across socioeconomic and geographic population groups.

METHODS

A questionnaire was used to collect data from randomly selected householders from 4,873 households (2,483 urban and 2,390 rural) in southeast Nigeria. Data was collected on: health problems that people had and sought care for; type of care sought, outpatient department (OPD) visits and inpatient department (IPD) stays; providers visited; expenditures; and preferences for improving access to care. Data was disaggregated by socio-economic status (SES) and geographic location (urban versus rural) of the households.

RESULTS

Malaria and hypertension were the major communicable and non-communicable diseases respectively that required OPD and IPD. Patent medicine dealers (PMDs) were the most commonly used providers (41.1%), followed by private hospitals (19.7%) and pharmacies (16.4%). The rural dwellers and poorer SES groups mostly used low-level and informal providers. The average monthly treatment expenditure in urban area was 2444 Naira (US$20.4) and 2267 Naira (US$18.9) in the rural area. Higher SES groups and urbanites incurred higher health expenditures. People that needed healthcare services did not seek care mostly because the health condition was not serious enough or they could not afford the cost of services.

CONCLUSION

There were inequities in use of the different providers, and also in expenditures on treatment. Reforms should aim to decrease barriers to access to public and formal health services and also identify constraints which impede the equitable distribution and access of public health services for the general population especially for poor people and rural dwellers.

Preferences for benefit packages for community-based health insurance: an exploratory study in Nigeria

Background

It is important that community-based health insurance (CBHI) schemes are designed in such a way as to ensure the relevance of the benefit packages to potential clients. Hence, this paper provides an understanding of the preferred benefit packages by different economic status groups as well as urban and rural dwellers for CBHI in Southeast Nigeria.

Methods

The study took place in rural, urban and semi-urban communities of south-east Nigeria. A questionnaire was used to collect information from 3070 randomly picked household heads. Focus group discussions were used to collect qualitative data. Data was examined for links between preferences for benefit packages with SES and geographic residence of the respondents.

Results

Respondents in the rural areas and in the lower SES preferred a comprehensive benefit package which includes all inpatient, outpatient and emergencies services, while those in urban areas as well as those in the higher SES group showed a preference for benefit packages which will cover only basic disease control interventions.

Conclusion

Equity concerns in preferences for services to be offered by the CBHI scheme should be addressed for CBHI to succeed in different contexts.

Willingness to pay for community-based health insurance in Nigeria: do economic status and place of residence matter?

OBJECTIVE

We examine socio-economic status (SES) and geographic differences in willingness of respondents to pay for community-based health insurance (CBHI).

METHODS

The study took place in Anambra and Enugu states, south-east Nigeria. It involved a rural, an urban and a semi-urban community in each of the two states. A pre-tested interviewer-administered questionnaire was used to collect information from a total of 3070 households selected by simple random sampling. Contingent valuation was used to elicit willingness to pay (WTP) using the bidding game format. Data were examined for correlation between SES and geographic locations with WTP. Log ordinary least squares (OLS) was used to examine the construct validity of elicited WTP.

RESULTS

Generally, less than 40% of the respondents were willing to pay for CBHI membership for themselves or other household members. The proportions of people who were willing to pay were much lower in the rural communities, at less than 7%. The average that respondents were willing to pay as a monthly premium for themselves ranged from 250 Naira (US$1.7) in a rural community to 343 Naira (US$2.9) in an urban community. The higher the SES group, the higher the stated WTP amount. Similarly, the urbanites stated higher WTP compared with peri-urban and rural dwellers. Males and people with more education stated higher WTP values than females and those with less education. Log OLS also showed that previously paying out-of-pocket for health care was negatively related to WTP. Previously paying for health care using any health insurance mechanism was positively related to WTP.

CONCLUSION

Economic status and place of residence amongst other factors matter in peoples' WTP for CBHI membership. Consumer awareness has to be created about the benefits of CBHI, especially in rural areas, and the amount to be paid has to be augmented with other means of financing (e.g. government and/or donor subsidies) to ensure success and sustainability of CBHI schemes.

Maternal morbidity and mortality in peri-urban Kenya--assessing progress in improving maternal healthcare

OBJECTIVE

Improving quality of maternal healthcare delivery is pivotal to reversing the trend of maternal health in developing countries and consequently, achieving the 5th millennium goal of reducing maternal mortality and improving universal access to reproductive health. Periodic facility-based reviews of maternal morbidity and mortality are crucial to improving quality of care delivered.

METHODS

This retrospective study was conducted in PCEA Kikuyu Hospital, Kenya. Data on sociodemographics, recorded antenatal care activities, maternal morbidities and deaths were elicited from case notes of all pregnancies and births over a 2 year period and subsequently analyzed.

RESULTS

There were 1716 deliveries during the period. 1405 (91%) of the women booked for antenatal care; 1068 (57.3%) had at least 3 visits before delivery. 842 (45.9%) were either untested for Human Immunodeficiency Virus or their results were not documented; 55 (3%) tested positive. The caesarean section rate was 27.4% (n=470); PMTCT (Prevention of Mother to Child Transmission) constituted 1.6% (10) of the indications. Urinary tract infection was the commonest maternal illness in pregnancy (14.5%, n=270), however, it was not found to be associated with any adverse outcome. Genital tract trauma was the commonest morbidity suffered by the women during delivery (90.6%, n=800). Psychological disorders constituted 5.3% (7) of reported postpartum complications. There were 2 maternal deaths out of 1673 live births, giving a maternal mortality ratio of 119.55 per 100,000 live births. The deaths resulted from septic abortion and eclampsia.

CONCLUSION

Urinary tract infection is an important cause of maternal illness during pregnancy. Routine screening is recommended. PMTCT needs further consolidation to increase the number of screened women and ensure those who need interventions like caesarean sections get access to them. Diagnosis and management of psychological disorders in pregnancy remain unsatisfactory. Further studies to identify the true burden of these conditions are needed.

Is community-based health insurance an equitable strategy for paying for healthcare? Experiences from southeast Nigeria

OBJECTIVES

To determine how equitable enrolment and utilization of community-based health insurance is in two communities with varying levels of success in implementing the scheme.

METHODS

The study was undertaken in two communities in Anambra state, southeast Nigeria. Data was collected using a questionnaire that was administered to 971 respondents in two communities selected by simple random sampling. Data analysis examined socio-economic status (SES) differences in enrolment levels, utilization, willingness to renew registration and payments.

RESULTS

Enrolment level was 15.5% in the non-successful community and 48.4% in the successful community (p<0.0001). However, there was no inequity in enrolment, willingness to renew registration and utilization of services. Equal amounts of money were paid as registration fee and premium by all SES quartiles. There were no exemptions and no subsidies.

CONCLUSION

Enrolment was generally low and contributions were retrogressive. The average premiums were also small. However, there was equitable enrolment and utilization of services. Efforts need to be made to increase the number of enrolees, so as to increase the pool of funds and risks. Payments by enrolees especially in poor and rural communities should be supplemented by subsidies from government and donors in order to ensure equitable financial risk protection.

Examining catastrophic costs and benefit incidence of subsidized antiretroviral treatment (ART) programme in south-east Nigeria

OBJECTIVES

To examine the extent to which costs of subsidized antiretrovirals treatment (ART) programmes are catastrophic and the benefit incidence that accrues to different population groups.

METHODS

Data on expenditures to patients for receiving treatment from a government subsidized ART clinic was collected using a questionnaire. The patient costs excluded time and other indirect costs. Catastrophic cost was determined as the percentage of total expenditure on ART treatment as a proportion of household non-food expenditures on essential items.

RESULTS

On average, patients spent 990 Naira (US$ 8.3) on antiretroviral (ARV) drugs per month. They also spent an average of $8.2 on other drugs per month. However, people that bought ARV drugs from elsewhere other than the ART clinic spent an average of $88.8 per month. Patients spent an average of $95.1 on laboratory tests per month. Subsidized ARV drugs depleted 9.8% of total household expenditure, other drugs (e.g. for opportunistic infections) depleted 9.7%, ARV drugs from elsewhere depleted 105%, investigations depleted 112.9% and total expenditure depleted 243.2%. The level of catastrophe was generally more with females, rural dwellers and most poor patients. Females and urbanites had more benefit incidence than males and rural dwellers.

CONCLUSION

Subsidized ART programme lowers the cost of ARV drugs but other major costs are still incurred, which make the overall cost of accessing and consuming ART treatment to be excessive and catastrophic. The costs of laboratory tests and other drugs should be subsidized and there should also be targeting of ART programme to ensure that more rural dwellers and the most-poor people have increased benefit incidence.