1. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 Examining community-based health insurance (CBHI) financial risk protection in southeast Nigeria by Chijioke Okoli, Obinna Onwujekwe, Benjamin Uzochukwu & Eric Obikeze Health Policy Research Group College of Medicine University of Nigeria, Enugu Campus

2. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 Outline  Background  Objective of study  Methods  Results  Discussion and conclusion

3. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011  Community- based health Insurance (CBHI) scheme is a non- profit type of health insurance used by poor people and those in the informal sector to protect themselves against the financial risk of illness.  CBHI is based on collective pooling of health risks  members pay small premiums on a regular basis to offset the risk of needing to pay large health care fees upon falling sick.  Membership in the scheme is voluntary Background

4. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011  In Anambra State, CBHI scheme was initiated in 2003 to restrain the dwindling health care delivery that arose due to: Budget constraint Health workers industrial action that lasted for one year and The consequent closure of all public health facilities  However, membership to scheme in the state is by individuals/households and a minimum of 500 persons were required to form a user group.  Members pay a N100 ($0.8) flat rate monthly, or yearly or in convenient instalments. Background contd

5. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011  The scheme is managed by 3 persons employed by the Community Health Committee (CHC).  The CHC is made up of :  the traditional ruler  the town union president  the town woman leader  representative of the Ministry of Health  representative of the Local Government Area  one male and one female from each of the community. Background contd

6. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011  To determine CBHI financial risk protection in two communities with varying success levels in implementing the scheme. Objective of study

7. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011  The study was undertaken in Anambra State, southeast Nigeria. population of about 4.1 million people. the state consists of 21 local government areas and 3 senatorial zone.  Prior to the study, CBHI was established in 10 communities namely:  Ifite Ogwari, Ugbene and Achala in Anambra north senatorial zone;  Abagana, Alor, Neni and Awka in Anambra central senatorial zone and  Igbokwu, Okija and Mbosi in Anambra south senatorial zone.  Apart from Awka, the state capital, all other communities are rural communities.  Each community has a health centre that serves between 4-7 villages Methods: study area

8. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011  The study was cross sectional - quantitative.  Out of the 10 pilot communities in 9 rural and 1 urban LGAs, 2 communities from 2 rural LGAs were selected for the study.  The 2 rural LGAs were selected because most of the LGAs where the scheme is piloted are rural and mainly inhabited by people in the informal sector.  One successful site (Igboukwu) and one not successful site (Neni) were purposively chosen.  CBHI scheme success was determined by enrolment data in the facilities being used as well as views of the state managerial team. Methods: Study design

9. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011  Quantitative and WTP data were collected using a pre-tested interviewer-administered questionnaire.  The contingent valuation method (CVM) was used to elicit WTP using the bidding game and structured haggling question formats.  Questionnaire was administered to 1000 households/respondents (i.e 500 per community)  Households were selected by simple random sampling from a sample frame of primary health care house numbering system.  Adequate sample size was determined, using a power of 80%, 95% confidence level and utilization rate of public health facilities of 20%.  The heads of households or their representatives (if the household head was absent) were interviewed. Sampling and sample size

10. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011  Demographic and socio-economic characteristics data as well as willingness to renew registration.  SES information on asset ownership and household weekly food expenditure were also collected.  Principal components analysis method was used to generate SES index in order to examine whether there were systematic differences in enrolment into the scheme.  the study populations were classified into four quartiles (least poor, poor, very poor and poorest)  The Kruskal-Wallis statistic was used to determine whether means of quartiles were significantly different. Data collection and analysis

11. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 SOCIO-ECONOMIC CHARACTERISTICS  A total of 455 and 516 questionnaires for Igboukwu and Neni respectively were available for analysis.  Majority of the respondents were females and wives or female household heads.  The highest level of education and occupation of enrollees in the scheme in both communities were primary education and petty trading. 36.5% in Igboukwu and 32.8% in Neni had primary education while 50.3% in Igboukwu and 61.4% in Neni were petty traders. Results

12. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011  Mean per capita household weekly food expenditure was N726.3 ($5.8) in Igboukwu and N508.1 ($4.1) for Neni. Result contd

13. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 Enrolment with CBHI

14. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 Reasons for registering

15. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011  Most respondents who registered did so because they perceived that the scheme offered financial risk protection  Availability of good quality drug was the next most common reason for registering in both communities.  Mean cost of registration was highest amongst the most poor in Igboukwu (N130.2, SD=128.3) and highest amongst the poor group in Neni Result contd

16. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 Willingness to renew

17. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011  Coverage was low in both communities but more especially in the community the scheme was less successful.  Although the average premiums were small, the contributions were regressive and unaffordable to the very poor.  For sustainability and financial viability of CBHI, efforts need to be made to increase the number of enrollees, so as to increase the pool of funds and risk sharing.  CBHI premiums should be supplemented by subsidies from government and donor funding in order to ensure equitable financial risk protection. Discussion and conclusion

18. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 Merci!

19. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 Consortium for Research on Equitable Health Systems (CREHS) Health Policy Research Group, Enugu, Nigeria Acknowledgment