|Year : 2020 | Volume
| Issue : 3 | Page : 196-201
Determinants of willingness to participate in health insurance amongst people living with HIV in a tertiary hospital in South-East Nigeria
Chihurumnanya Nwachi Alo, Ijeoma Nkem Okedo-Alex, Ifeyinwa Chizoba Akamike
Department of Community Medicine, Federal Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
|Date of Submission||16-Jan-2019|
|Date of Decision||30-Apr-2019|
|Date of Acceptance||13-May-2020|
|Date of Web Publication||17-Jul-2020|
Dr. Ijeoma Nkem Okedo-Alex
Department of Community Medicine, Federal Teaching Hospital, Abakaliki, Ebonyi State
Source of Support: None, Conflict of Interest: None
Background: Waning donor funding and poor country ownership of HIV care programmes are challenges for the sustainability of care for people living with HIV (PLHIV) in Nigeria. Health insurance presents a viable alternative for funding of HIV care services. This study assessed the determinants of willingness to participate in health insurance amongst PLHIV in a tertiary hospital in South-East Nigeria.
Methods: Across-sectional survey was conducted amongst 371 PLHIV on treatment at Federal Teaching Hospital, Abakaliki, Nigeria, using a semi-structured, interviewer-administered questionnaire. Chi-square test and logistic regression were conducted with SPSS version 20 at 5% level of significance.
Results: Respondents were mostly males (51.8%) with a mean age and monthly income of 45.4 ± 10.3 years and $74.1 ± 42, respectively. Majority were willing to participate (82.5%) and to finance health insurance (65.2%). The major reasons cited by those unwilling to participate were poor understanding of how the system works and lack of regular source of income. The predictors of willingness to participate were female gender (adjusted odds ratio [AOR] = 2.9; 95% confidence interval [CI]: 1.6–5.7), being currently unmarried (AOR = 4.3; 95% CI: 2.3–7.8), being self-employed (AOR = 2.2; 95% CI: 1.2–3.9), having family size >5 (AOR = 3.1; 95% CI: 1.7–5.9) and having less than secondary school education (AOR = 4.3; 95% CI: 2.3–7.8).
Conclusion: Majority of the respondents surveyed were willing to participate in, and finance health insurance. Willingness to participate was more amongst vulnerable subgroups (females, unmarried, self-employed, poorly educated and those with large family size). We recommend the inclusion of health insurance in the care package of PLHIV.
Keywords: Determinants, health insurance, Nigeria, people living with HIV, willingness to participate
|How to cite this article:|
Alo CN, Okedo-Alex IN, Akamike IC. Determinants of willingness to participate in health insurance amongst people living with HIV in a tertiary hospital in South-East Nigeria. Niger Postgrad Med J 2020;27:196-201
|How to cite this URL:|
Alo CN, Okedo-Alex IN, Akamike IC. Determinants of willingness to participate in health insurance amongst people living with HIV in a tertiary hospital in South-East Nigeria. Niger Postgrad Med J [serial online] 2020 [cited 2020 Aug 11];27:196-201. Available from: http://www.npmj.org/text.asp?2020/27/3/196/289904
| Introduction|| |
Annually, approximately 100 million people become poor because of out-of-pocket spending (OOPS) on their health. An additional 1.2 billion who are already poor become poorer because of this same out-of-pocket expenditure on health. Because health and poverty are closely related, households who experience both ill-health and poverty are adversely affected. This further deters the attainment of universal health coverage, which is aimed at protecting people from financial suffering due to catastrophic health spending.,,
Households headed by or having individuals who have chronic diseases such as HIV are at a higher risk for catastrophic health expenditure (CHE) than others. This is largely due to further impoverishment in already poor households and lack of health insurance, which has been identified as the enablers of CHE.,,, Lack of insurance and financial constraints are the commonly reported barriers to HIV care and treatment. Morbidity due to HIV has been shown to impact negatively on economic productivity and result in loss of means of livelihood, thus further perpetuating poverty.
For over 11 years, free antiretroviral (ARV) treatment at selected health facilities in Nigeria has significantly improved the uptake of treatment., The free HIV/AIDS services in Nigeria are largely donor supported although PLHIV still bear considerable costs of care by paying out of pocket for medical costs such as hospital consultations, ARV and non-ARV drugs, costs due to HIV-linked illnesses and laboratory services, as well as nonmedical costs such as food and transport costs., Despite the availability of free services, 3.2%–100% of Nigerian households with someone living with HIV experience CHE, especially for inpatient hospitalisations. To survive this, many households with someone living with HIV have to sacrifice other basic needs, sell assets or incur debts to fund their care.,,,,
Given the waning donor funding, the chronicity of HIV care, the poor preparedness of national governments to take over funding and the need to sustain gains made toward achieving the 90-90-90 targets for ending the HIV/AIDS pandemic, there is need to assess the willingness of PLHIV to participate in health insurance as a viable alternative for funding of HIV care services.
Only a few studies have assessed willingness to participate or pay for particular care services amongst people living with HIV (PLHIV). These show that 34%–79% of PLHIV were willing to pay for drugs or health insurance programmes at different costs., Similarly, other studies amongst non-HIV clients have shown that the majority were willing to participate in health insurance., Previous studies have shown that factors such as awareness of health insurance, marital status, age, sex, household size, educational status and payment constraints in the past can influence willingness to participate in health insurance.,, However, there is a paucity of literature on willingness to participate in health insurance amongst PLHIV. The aim of this study was to assess the willingness to participate in health insurance and associated predictors amongst HIV patients receiving care in a tertiary hospital in South-East Nigeria.
| Methods|| |
Study area and design
A descriptive cross-sectional study was conducted over 3 months (May–July 2018) amongst PLHIV receiving care at Federal Teaching Hospital, Abakaliki (FETHA), Ebonyi State, South-East Nigeria. The FETHA is a public health facility and the only teaching hospital in Ebonyi State. The teaching hospital has two arms (FETHA 1 and FETHA 2) located in different parts of Abakaliki, Ebonyi State.
With support from the Centre for Clinical Care and Research Nigeria, it serves as the largest comprehensive treatment centre for HIV/AIDS in the State with clientele from neighbouring South-East and South-South States. Both adult and paediatric HIV/AIDS care and treatment services are provided by medical doctors and trained nurses in its two locations. The communicable disease control and AIDS relief centre in FETHA 2 provide HIV/AIDS care and treatment services for adult patients, while FETHA 1 is focused on care for pregnant women and children. As of when this study was conducted, there were 1500 adult clients enrolled on HIV/AIDS care and treatment in the facility. The adult clinic is run all days of the week, except Fridays and weekends.
The Research and Ethics Committee of FETHA, Ebonyi State, provided ethical approval for this study. The ethical clearance was obtained on 20th February 2018, with ethical approval number 24/01/2018-19/02/2018. We obtained written informed consent from the study participants and ensured the confidentiality of their responses.
Study population and sampling technique
The study population comprised of adults who were enrolled in and receiving treatment from the clinic providing HIV/AIDS care in the hospital. Those <18 years of age, not on ARV therapy, too ill to participate or who withheld informed consent were excluded from the study.
The sample size was determined using 95% confidence level, 5% precision, and 40% as the proportion of clients who are willing to participate in health insurance. A minimum sample size of 297 was calculated after adjusting the initially calculated sample size of 369 using a finite population correction factor [(N/[n + N – 1)]. The sample size was increased to 371 to accommodate for non-response using the formula: 1/(1 − NR)., Systematic random sampling was used to select the participants at a sampling interval of 4 (k = 1500/371). The attendance/appointment registers were used to construct the sampling frame from which the participants were selected.
A pretested semi-structured questionnaire was used to collect the information from 371 participants.
The study tool collected information on the sociodemographic characteristics, clinical characteristics, willingness to participate in and finance health insurance and reasons for non-willingness to participate in health insurance. The research assistants were public health resident doctors undergoing their senior residency programme in FETHA.
The independent variables were sociodemographic characteristics such as age, sex, marital status, residence, religion, family size, educational status, occupation and monthly income, while the dependent variable was the willingness to participate in health insurance. Data entry and analysis were performed using the IBM Statistical Package for the Social Sciences for Windows version 20.0 (IBM Corp., Armonk, N.Y., USA). For qualitative variables, frequencies and proportions were calculated, while means and standard deviations were calculated for quantitative variables. Chi-square statistics was used to determine the relationship between the dependent variable and the independent variables at 95% level of statistical significance (P < 0.05).
Following Chi-square analysis, the independent variables that were significant at 10% significance level were selected and modelled in multiple logistic regression to isolate factors that predict the dependent variable at 5% level of significance.
| Results|| |
The response rate was 100% (n = 371). Slightly more than half (192/371, 51.8%) of the respondents were males, with a mean age of 45.4 ± 10.3 years. Almost half of the respondents were married (177/371, 47.7%) and had post-secondary education (179/371, 48.2%). Most of the respondents lived in the urban area (275/371, 74.1%). The mean family size and monthly income of the respondents were 4.86 ± 2.52 and $74.1 ± 42.1 (N26,665.77 ± 15,171.50), respectively [Table 1].
Most of the respondents (306/371, 82.5%) were willing to participate in health insurance; however, 34.8% of them were unwilling to finance their involvement in health insurance. The major reasons cited by those unwilling to participate in health insurance were poor understanding of how the system works (81/371, 21.8%), lack of regular source of income (43/371, 11.6%), health insurance not needed (16/371, 4.3%) and fear of poor management of resources (16/371, 4.3%) [Table 2].
|Table 2: Willingness to participate in health in health insurance amongst people living with HIV in a tertiary hospital in Nigeria|
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Gender, marital status, religion, employment status, educational level, family size, residence and monthly income were significantly associated with willingness to participate in health insurance. Willingness to participate was higher amongst men than women (176/192, 91.7% vs 130/179, 71.6%; P < 0.001), never married/others than married (178/194, 91.8% vs 128/177, 72.3%; P < 0.001) and Christians than Muslims (306/355, 86.2% vs 0/16, 0%; P < 0,001). More of the self-employed were willing to participate in health insurance compared to those in paid employment (210/243, 86.4% vs 96/128, 75.0%; P = 0.006). Willingness to participate was higher amongst the respondents with primary education and less and secondary education than those with tertiary education (96/96, 100% vs 130/179, 72.6%). Respondents with six or more members in their family were more willing to participate than those with less (145/161. 90.1% vs 161/201, 76.7%; P = 0.001). Rural dwellers were more willing to participate in health insurance than urbanites (96/96, 100% vs 210/275, 76.4%; P < 0.001). Willingness to participate was higher amongst respondents that earned more than $111.1 (N40,000) monthly than other categories of income (P < 0.001) [Table 3].
|Table 3: Factors associated with willingness to participate in health insurance amongst people living with HIV in a tertiary hospital in Nigeria|
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Women were three times more likely to be willing to participate in health insurance than their male counterparts (adjusted odds ratio [AOR] 2.9; 95% confidence interval [CI] 1.6–5.7). Those with at most a secondary school education were also four times more likely to be willing to participate than those with tertiary education (AOR 4.3; 95% CI 2.3–7.8). Those with a family size >6 had three times more odds of being willing to participate in health insurance than those with smaller family size (AOR 3.1; 95% CI 1.7–5.9). Those who were not currently married (comprising never married, divorced and widowed) had four times more odds of being willing to participate in health insurance than the married (AOR 4.3; 95% CI 2.3–7.8). The self-employed were 2.2 times more likely to be willing to participate in health insurance than those in paid employment (AOR 2.2; 95% CI 1.2–3.9) [Table 4].
|Table 4: Binary logistic regression model for predictors of willingness to participate in health insurance amongst people living with HIV in a tertiary hospital in Nigeria|
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| Discussion|| |
This study assessed the willingness to participate in health insurance and the associated determinants amongst PLHIV in FETHA, Ebonyi State.
Majority (82.5%) of the respondents were willing to participate in health insurance. This finding is further underscored by the fact that many of the respondents (65.5%) belonged to occupations within the informal sector and thus were not accommodated within the National Health Insurance Scheme (NHIS). Since the inception of NHIS in 2005, only federal formal sector employees, representing <5% of the Nigerian working population, have been enrolled. In addition, most of the respondents (82.5%) earn <111 Dollars (N40, 000) in a month. This high level of willingness to participate in health insurance seen in our study is similar to the findings in another study conducted amongst PLHIV and also agrees with similar studies carried out on health insurance amongst other groups whose HIV status was not specified.,, This high level of inclination towards participating in health insurance has also been documented in similar studies on the NHISs.,,, This readiness to be part of a health insurance scheme is however not surprising; given the impoverishment, many PLHIV and their families face from large OOPS due to both medical and nonmedical costs.,, Since existing free/subsidised HIV care services have not decreased CHE and in the light of donor fatigue for sponsorship of free ARV drugs, health insurance programmes should be considered important amongst PLHIV in Nigeria, who additionally have considerable increase in morbidity, health-care utilisation, public health facility use, lost work time and family time devoted to caregiving.
The positive attitude towards health insurance amongst this vulnerable group (PLHIV) will be advantageous in the design of health insurance programmes that have simplified enrolment procedures, affordable/subsidised premiums, quality service packages and management. Similarly, the majority of the respondents were also willing to finance health insurance. This is similar to the findings from other studies. In contrast, some studies on willingness to pay for ARV drugs have found that only a third of the PLHIV studied were willing to pay the first bid for the ARV drugs. Likewise, in another study conducted in South-East Nigeria, less than two-fifths of the respondents were willing to pay for self and household health insurance membership.
The most cited reasons for unwillingness to participate in health insurance by our respondents were poor understanding of how the system works, lack of regular source of income, health insurance not needed and fear of poor management of resources. Similarly, other studies have also cited financial constraints, lack of faith in the system, poor quality/coverage of services, lack of decision-making ability and lack of awareness/interest as the commonly cited reasons for unwillingness in joining health insurance schemes.,,,, These highlight both demand- and supply-side factors for an effective health insurance scheme. To address these, there is need to increase awareness on the need for health insurance and how it works, build trust by transparent and effective management, provide quality care and subsidise costs for the poorest of the poor PLHIV who may not have regular sources of income and thus not afford to pay the insurance premiums. Our study showed that gender, marital status, occupational status, educational status, religion, place of residence, monthly income and family were significantly associated with willingness to participate in health insurance amongst the respondents. This agrees with the findings from other studies.,,,,
Regarding determinants, willingness to participate in health insurance was significantly higher amongst the vulnerable subgroups. These were women, the less educated, those with large family size, those currently unmarried and the self-employed. Women were three times more likely to be willing to participate in health insurance than their male counterparts. This could be because women tend to be more health conscious and have more reasons (obstetrics and gynaecology-related) to utilise healthcare services than their male counterparts. Those with at most a secondary school education and below were also four times more likely to be willing to participate than those with tertiary education. The less educated are more prone to catastrophic spending from out-of-pocket expenditure and so would prefer to be on insurance. However, higher levels of willingness to pay for health insurance have been elicited for males and the more educated. Those with a family size >5 had three times more odds of being willing to participate in health insurance than those with smaller family size. Large household size has been associated with high OOPS and high incidence of CHE,, and thus, viable options to reduce such impoverishing expenditure will be appealing to such respondents. Those who were not currently married (comprising never married, divorced and widowed) had four times more odds of being willing to participate in health insurance than the married. Lack of financial support from a spouse could result in more financial burdens, hence their willingness to be part of a fund/risk pooling arrangement.
The strengths of this study are as follows: to the best of our knowledge, it is amongst the few studies to examine the willingness to participate in health insurance and its determinants amongst PLHIV in Nigeria. The study also had a high response rate as all selected participants consented to the study. The use of only one teaching hospital for the study may limit the generalisability of the study findings.
| Conclusion|| |
The majority of the PLHIV surveyed were willing to participate in health insurance. Being a woman, self-employed, currently unmarried and less educated and having a large family size were the determinants of willingness to participate in health insurance amongst the respondents. To improve continuity of care and reduce catastrophic spending on health amongst PLHIV, there is a need to harness this expressed willingness to participate amongst PLHIV in the design of subsidised and sustainable health insurance programmes with special focus on the socially disadvantaged groups amongst them.
We acknowledge all the research assistants and PLHIV clients who participated in the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. The World Health Report: Health Systems Financing: The Path to Universal Coverage. Geneva, Switzerland: World Health Organization; 2010.
World Health Organization Regional office for the Eastern Mediterranean. Technical Paper: The Impact of Health Expenditure on Households and Options for Alternative Financing. Alexandria: 2004.
Aregbesola BS, Khan SM. Determinants of catastrophic health expenditure in Nigeria. Eur J Heal Econ 2018;19:521-32.
Buigut S, Ettarh R, Amendah DD. Catastrophic health expenditure and its determinants in Kenya slum communities. Int J Equity Health 2015;14:46.
Barasa EW, Maina T, Ravishankar N. Assessing the impoverishing effects, and factors associated with the incidence of catastrophic health care payments in Kenya. Int J Equity Health 2017;16:31.
Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJ. Household catastrophic health expenditure: A multicountry analysis. Lancet 2003;362:111-7.
Ghorbanian A, Rashidian A, Bagheri Lankarani K, Kavosi Z. The Prevalence and Determinants of Catastrophic Health Expenditures in Iran: A Systematic Review and Meta-Analysis, Health Scope. 2019; 8:e63210. doi: 10.5812/jhealthscope.63210.
Dombrowski JC, Simoni JM, Katz DA, Golden MR. Barriers to HIV care and treatment among participants in a public health HIV care relinkage program. AIDS Patient Care STDS 2015;29:279-87.
Ndukwe CD, Ibekwe PN, Olakunde BO, Ogungbemi K, Fatungase KO, Anenih JO, Anosike AO, et al
. Out-of-pocket expenditure on HIV/AIDS services in Nigeria. Int J Health Allied Sci 2018;7:1-5. [Full text]
Onwujekwe OE, Ibe O, Torpey K, Dada S, Uzochukwu B, Sanwo O. Examining geographic and socio-economic differences in outpatient and inpatient consumer expenditures for treating HIV/AIDS in Nigeria. J Int AIDS Soc 2016;19:20588.
Onwujekwe O, Dike N, Chukwuka C, Uzochukwu B, Onyedum C, Onoka C, et al
. Examining catastrophic costs and benefit incidence of subsidized antiretroviral treatment (ART) programme in South-East Nigeria. Health Policy 2009;90:223-9.
Etiaba E, Onwujekwe O, Torpey K, Uzochukwu B, Chiegil R. What is the economic burden of subsidized HIV/AIDS treatment services on patients in Nigeria and is this burden catastrophic to households? PLoS One 2016;11:e0167117.
Trivedi M, Raman AV. Financial implication of hospitalization and willingness to join health insurance programme among people living with HIV in India. Amity J Healthc Manage 2016;1:21-32.
Mbachu C, Okoli C, Onwujekwe O, Enabulele F. Willingness to pay for antiretroviral drugs among HIV and AIDS clients in South-East Nigeria. Health Expect 2018;21:270-8.
Azuogu BN, Madubueze UC, Alo C, Ogbonnaya LU, Ajayi NA. Level of awareness, and factors associated with willingness to participate in the National Health Insurance Scheme among traders in Abakaliki main market, Ebonyi State, Nigeria. Afr J Med Health Sci 2016;15:18-23. [Full text]
Agago T, Woldie M, Ololo S. Willingness to join and pay for the newly proposed social health insurance among teachers in Wolaita Sodo town, South Ethiopia. Ethiop J Health Sci 2014;24:195-202.
Adebayo EF, Uthman OA, Wiysonge CS, Stern EA, Lamont KT, Ataguba JE. A systematic review of factors that affect uptake of community-based health insurance in low-income and middle-income countries. BMC Health Serv Res 2015;15:543.
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;25:155-61.
Araoye MO. Research Methodology with Statistics for Health and Social Sciences. 1st
ed. Ilorin: Nathadex Publishers; 2004.
Onwasigwe C. Principles & Methods of Epidemiology. 2nd
ed. Enugu: EL'Demak; 2010.
Gupta I, Trivedi M. Willingness to pay for health insurance among HIV-positive patients in India. Appl Health Econ Health Policy 2014;12:601-10.
Adedeji AS, Doyin A, Kayode OG, Ayodele A. Knowledge, practice, and willingness to participate in community health insurance scheme among households in Nigerian capital city. Sudan J Med Sci 2017;12:9-18.
Oriakhi HO, Onemolease EA, Health N, Scheme I, State E. Determinants of rural household's willingness to participate in community based health insurance scheme in Edo State, Nigeria. Ethno Med 2012;6:95-102.
Ilesanmi OS, Adebiyi AO, Fatiregun AA. National health insurance scheme: How protected are households in Oyo State, Nigeria from catastrophic health expenditure? Int J Health Policy Manage 2014;2:175-80.
Omotowo IB, Ezeoke UE, Obi IE, Uzochukwu BS, Agunwa CC, Eke CB, et al
. Household perceptions, willingness to pay, benefit package preferences, health system readiness for national health insurance scheme in Southern Nigeria. Health (Irvine Calif) 2016;8:1630-44.
Mahal A, Canning D, Odumosu K, Okonkwo P. Assessing the economic impact of HIV/AIDS on Nigerian households: A propensity score matching approach. AIDS 2008;22 Suppl 1:S95-101.
Meng Q, Yuan B, Jia L, Wang J, Yu B, Gao J, et al
. Expanding health insurance coverage in vulnerable groups: A systematic review of options. Health Policy Plan 2011;26:93-104.
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.
Bamidele J, Adebimpe W. Awareness, attitude and willingness of artisans in Osun state South-Western Nigeria to participate in community based health insurance. J Community Med Prim Health Care 2013;24:1-10.
[Table 1], [Table 2], [Table 3], [Table 4]