|Year : 2014 | Volume
| Issue : 1 | Page : 27-31
Sources of health care financing among patients at the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
Adegboyega O. Oyefabi1, Alhaji A. Aliyu1, Ahmed Idris2
1 Department of Community Medicine, ABUTH, Zaria, Nigeria
2 Department of Business Administration, ABU, Zaria, Nigeria
|Date of Web Publication||15-May-2014|
Dr. Adegboyega O. Oyefabi
Department of Community Medicine, ABUTH, Zaria
Source of Support: None, Conflict of Interest: None
Introduction: Health care financing is the mobilization of funds for health care services. This study determined the various sources of health care financing among the patients on admission at the Ahmadu Bello University Teaching Hospital (ABUTH), Shika-Zaria in 2011 and the effects of the medical bills on the patients and their family members.
Methodology: A multi-staged sampling technique was used to select 100 clients for the study. The clients were stratified into the four major wards of the ABUTH; the medical, surgical, obstetrical and gynecological and the pediatric wards. A total of 25 clients were equally allocated to each ward and these were then selected by balloting. Information was sought on their socio-demographic characteristics, sources of the health care financing and the adverse effects of the medical bills on the patients and their family members.
Results: Majority of the clients were married, Hausa Muslim housewives who earned < N5,000/month (less 1 $/day). Most were aged between 20 and 29 (34%) with a mean age of 36.7 years. Patients' relatives paid for the medical bill in most of the cases (48%), 37% paid through out of pocket, while 11% used the National Health Insurance Scheme (NHIS) respectively. The medical expenses affected family feeding (29.3%), while 16% of the patients could not get full medical services due to lack of funds, 8.8% could not pay school fees of their children and 12.2% were indebted. There were no significant association between the age, sex, marital status, monthly income, occupational status and the clients' sources of health care financing. Majority of the clients (65%) were not aware of the NHIS. Most (80%) of the patients would want to use the health insurance scheme (NHIS) if they have access to the opportunity.
Conclusions: The main source of health care financing in this tertiary center was through out of pocket expenditure by patients and their relatives.
Recommendation: There is a need for the urgent implementation of the community health insurance scheme in Nigeria for the benefit of the less privileged.
Keywords: Community, expenditures, health care, insurance, out of pockets
|How to cite this article:|
Oyefabi AO, Aliyu AA, Idris A. Sources of health care financing among patients at the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. J Med Trop 2014;16:27-31
|How to cite this URL:|
Oyefabi AO, Aliyu AA, Idris A. Sources of health care financing among patients at the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. J Med Trop [serial online] 2014 [cited 2021 Apr 20];16:27-31. Available from: https://www.jmedtropics.org/text.asp?2014/16/1/27/132574
| Introduction|| |
The World Health Organization defined health in 1946 as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.  While health care can be defined as the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in humans. The exact configuration of health care systems varies from country to country, but in all cases requires a robust financing mechanism; a well-trained and adequately-paid workforce; reliable information on which to base decisions and policies; and well maintained facilities and logistics to deliver quality health care services and technologies. 
The main methods of financing for health care include the National Health Insurance Scheme (NHIS), general revenue, private insurance, community-based insurance and out-of-pocket payments.  The choice of a method of financing health care delivery by an individual or an organization has a great impact on the individual who bears the financial burden, the amount of resources available for health care and who manages the allocation of resources.  There is a cycle of relationship between health, poverty and disease. Poverty is the root cause of many diseases.  The health care seeking behavior of an individual or a family is also influenced by the ability to pay for the health services. Many Nigerians cannot afford going to the hospitals because of the inability to pay for the health care services.  They rather patronize quacks and roadside drug vendors. Even in states where healthcare is free for the elderly, pregnant women and children under-five, many complain not having enough money for transport and other logistics. 
To address this problem, the Federal Government of Nigeria introduced the NHIS. Health insurance is a social security system that guarantees the provision of needed health services to persons on the payment of token contributions at regular intervals.  The NHIS is a corporate body set up under act 35 of 1999 by the federal government to improve the health of all Nigerians at an affordable cost through various pre-payment systems.  But 13 years after, <6 million Nigerians are benefiting from the scheme. The beneficiaries are civil servants in Federal employment.
Health care provision in Nigeria has been the concurrent responsibility of the three tiers of government in the country. However, because Nigeria operates a mixed economy, private providers of health care have a visible role to play in health care delivery. The federal government's role is mostly limited to coordinating the affairs of the university teaching hospitals and the federal medical centers in various parts of the country, while the state government manages the various state general hospitals and the local government focus on the primary health care centers and dispensaries.  The total expenditure on health care as a percentage of GDP is 4.6%, while the percentage of the federal government expenditure on health care is about 1.5% for government employees and private firms entering contracts with private health care providers.  But only few people still have access to the NHIS. Many states and local governments are yet to implement the scheme. 
This has led to a growing concern about the economic impact of health care expenditure on families and individuals who face illness, particularly when pre-payment mechanisms do not exist and households have to make out of pocket expenditures to use health services. In Nigeria, private expenditure accounts for almost 70% of total expenditure on health of which more than 90% is out-of-pocket. , This high level of out-of-pocket expenditure implies that health care can place a significant financial burden on households. 
Payment for health care is therefore said to be catastrophic when it leads the household to sacrifice consumption of other items that are necessary for their well-being such as shelter or education. For families living close to the poverty line, even low levels of expenditure on health care may be sufficient to tip them into poverty. Past research studies have set the threshold level for catastrophic expenditure on health services at a range from 5% to 40% of total household expenses.  The National Health insurance was established to address this menace by providing a social health insurance through which all Nigerians can obtain a respite from this catastrophic expenditures on their health. 
This research examined the sources of health care financing for patients on admission at the Ahmadu Bello University Teaching Hospital (ABUTH), Zaria and how these choices of finance affect the families and the individual client's socioeconomic life.
| Methodology|| |
The ABUTH, Zaria is one of Nigerian's first generation teaching hospitals. The institution was designed from inception to serve as the major tertiary health center for the defunct northern region. This is the basis of its, hitherto multicenter structures, it is the largest health facility within the northwest geopolitical region with regards to both size and personnel.
The ABUTH ultra-modern complex is located in Shika, Giwa Local Government, in Kaduna state. It is located about 2 km from Shika town and bounded by Ahmadu Bello University (ABU) on the South, Shika town on the North and Milgoma town on the East. ABUTH was established as institute of health in 1968 by statute 15 of the ABU law by the then Northern Nigerian government with the objective of providing facilities for training of doctors and other health professionals and for the provision of health care to the people. The ABUTH has facilities spread out between Kaduna, Zaria in Kaduna state and Malumfashi in Katsina state with bed capacity of 1220, about 59 specialist clinics, outpatient services and 24 h emergency services. It became ABUTH by decree 10 of January 1, 1985 maintaining its three branches in Kaduna, Zaria and Malumfashi.
The hospital re-located to its permanent site on November 25, 2005, and currently has a bed capacity of about 430 beds, staff strength of about 4,000 and a total patient admission turnover of more than 10,000 annually and is also the center of excellence for radiotherapy and oncology. ABUTH Kaduna is one of the three-unit hospitals that constitute the ABUTH complex. It is a major referral center in Kaduna town and its environment.
The hospital has clinical departments, wards, outpatient department, Radiology Department, Accident and Emergency Unit, laboratories, operating theatres, clinics, intensive care unit (ICU), administrative department, etc., Majority of the hospital in-patients are admitted in obstetrics and gynecology, medical, surgical and pediatric wards. Patients in these four wards were the focus of this study. The hospital, as a referral center receives clients from Kaduna, Katsina, Plateau, Bauchi, Sokoto, and Zamfara states. There are also referral cases from other tertiary health facilities all over the nation. Majority of the clients were indigenous Hausas and Fulanis, although the Igbos and the Yorubas ethnic groups also constitute a substantial proportion of clients. Most of the clients are petty traders, farmers, businessmen and civil servants.
Patients who were on admission in the pediatric, medical, surgical, and obstetrics and gynecology wards constituted the study population. This study was conducted in June 2011.
Study Design/Methods of Data Collection
A descriptive cross-sectional survey of the patients on admission at the ABUTH was carried out to determine the sources of health care financing by these patients. A multistage sampling technique was used to sample respondents as follows:
- Stage 1: Patients on admission were stratified to four major wards of the hospital: Medical, pediatric, surgical, obstetrics and gynecology
- Stage 2: The simple random sampling technique (balloting) was then used to select 25 patients equally from each of these wards using the admission registers containing the names of all the patients on admission as the sampling frame in each ward. There were 72, 66, 72 and 55 clients, respectively in surgery, obstetrics and gynecology, medicine and pediatric wards, respectively during the period of this study. The care givers of the children in the pediatric ward responded on behalf of the admitted children.
The sample size for the study was calculated using the Fisher's formula for the sample size calculation:
n =Z2pg / d2
n = desired sample size
Z = obtained from the normal distribution table = 1.96
P = proportion of adults with no health insurance scheme in Nigeria was (male 97%, female 98%, average 97.5%)  therefore P = 97.5/100 = 0.975
q = complimentary probability to P = (1-P) =0.025
d = Degree of accuracy (precision) desired here set at 0.05.
The minimum sample size was approximately 38 clients.
In order to make the sample large enough to allow for the validity of the significance test, make provision for clients who may decline to participate, provide the desired level of accuracy and permit appropriate analysis the study population was increased to 100 clients/group.
A structured, close ended and interviewer administered questionnaire was used as the instrument for data collection from the clients. The patients who were admitted in wards like the accident and emergency, ICUs, those on observations at the general outpatients and day clinics and those on admission but not willing to participate in the study were excluded from the study.
The IBM Statistical Package for Social Sciences version 18 and IBM Microsoft Excel 2007 were used for data entry and analysis. The results were subsequently presented in statistical form as charts and tables. Chi-square was used to test for statistical associations of interest. Statistical significance was set at P ≤ 0.05. The limitation of this study is that it is a hospital-based study and thus may not fully reflect the impact of the sources of finance on health seeking behavior of the clients.
Approval was obtained from the ethical and scientific committee of the ABUTH, Zaria to carry out the study. The consent of the clients on admission was also obtained after a careful explanation of the concept to the clients and their relatives. The clients were assured that the information given was only meant for the purpose of the research. No form of identity was recorded on the questionnaires to ensure confidentiality.
| Results|| |
[Table 1] shows socio-demographic characteristics of respondents. Mean age was 36.7 ± 4.3 years. Relatives paid for the medical bills in 48% of cases, 37% were through out of pocket while 11% of clients used NHIS respectively [Table 2]. The various effects of medical payments on the clients and their families are shown in [Table 3]. Nearly 8% of the clients could not pay the school fees of their wards and 12.2% became indebted. There were no statistical significant relationship between age, sex, marital status, monthly income, occupation, and clients' sources of health care financing. Majority of clients (65%) were not aware of NHIS [Table 4].
|Table 3: The effects of medical expenses on the patients and their family (n=100)|
Click here to view
| Discussion|| |
Majority of our respondents were female, married, Hausa housewives, who earn <5,000 naira/month, this is less than a dollar/day, which is defined as extreme poverty.  About one third had no formal education which might have contributed to delay in seeking medical care. Educational factors has also been associated to many health complications in Nigeria,  These socio economic problems has been the focus of the millennium development goals.  The modal age group is age 20-29 (34%) with a mean age of 36.7 ± 4.3 years. This falls within the reproductive and working age group which is consistent with the report of an earlier demographic and health survey in Nigeria.  It is noteworthy that 20% of this population is unemployed while 34% are housewives without any other means of livelihood and 15% are petty traders. This is comparable to the 40% national unemployment rate in Nigeria.  This majority of the clients that should constitute a part of our national work force are sick and could not afford the medical bill largely because they were not employed and the Nigeria national insurance scheme focuses on government employees for now.  They and their equally poor family relatives are therefore forced to result to selling their personal belongings to divert money meant for basic necessities of life to pay for their health services.  About 38% of the clients admitted they earn less than a dollar per day, but according to the World Bank, 66% of the Nigerian population now falls below the poverty line of about a dollar a day compared with 43% in 1985.  From this analysis therefore, it is clear that the majority of the clients on admission in this tertiary institution are the extremely poor.  The relatives of the patients pay for the medical bill in the majority (48%) of cases. This is a form of out of pocket payment, while the sick person directly pays for his ailments in 37% of the cases. However, this is not without untoward catastrophic effects on the family members as this affects their feeding (29%) and school fees (8.5%).  Several studies have shown a significant relationship between the uptake of the social health care financing scheme, the socio-economic status of the clients and its proxies. ,
The major indications for admission were gastrointestinal diseases (14%), cancer such as cervical cancer (13%), cardiovascular diseases such as hypertension (13%), diabetic mellitus (11%), and febrile illness like malaria (10%), respiratory tract infection (10%), and genitourinary tract infection (9%). These are preventable diseases but for the interplay of disease, poverty and ignorance militating against these patients.  This also explains the delay in seeking medical help in this hospital. The patients prefer to seek help first through self-medications, traditional herbal medicine and then the patent medicine store and cheap but substandard private clinic in a bid to beat the cost of health care at the tertiary institution when. It is only when all this fail that most patients are seen at the tertiary facilities. Patient delay has been shown to worsen the medical condition in previous studies.  This has been further illustrated by the concept of the iceberg phenomenon.  It has also been shown from this study that 37% of the patients can delay up to 3 weeks, and 24% between 1 and 3 months delay before seeking medical care at the tertiary center, a time that complications might probably have developed, with the chance of survival very thin due to further suffering and deterioration in health. 
Finally, this study has shown no significant association between the age, sex, occupation, income, the educational level, and sources of health care financing. This may not really be surprising since the majority of the patients are within similar socio-economic strata. A significant association might exist if different social cadre of clients is on admission at this health facility.
| Conclusion|| |
The main source of health financing, out of pocket payment for medical bills, has been shown in this study to be due to the lack of awareness on the NHIS with catastrophic effects on the family members. There is a need for community education on the NHIS in Nigeria and the extension of the services to the informal sectors and the less privilege in the communities.
| References|| |
|1.||The World Health Report 2000. Health Systems: Measuring Performance. Geneva: World Health Organization; 2000. |
|2.||Osibogun A. The National Health Insurance Scheme: Some myths and realities. Journal of Community Medicine and Primary Health Care 2000;12:1-3. |
|3.||National Health Insurance Scheme. Operational Guideline. Abuja: NHIS: 2005. |
|4.||Onoka CA, Hanson K, Onwujekwe O, Uzochukwu B. Examining catastrophic health expenditures at variable thresholds using household consumption expenditure diaries. Tropical Medicine and International Health 2011;16:1334-41. |
|5.||Onwujekwe O, Hanson K, Uzochukwu B, Ichoku H, Ike E, Onwughalu B. Are malaria treatment expenditures catastrophic to different socio-economic and geographic groups and how do they cope with payment? A study in southeast Nigeria. Trop Med Int Health 2010;15:18-25. |
|6.||Ibiwoye A, Adeleke IA. Does national health insurance promote access to quality health care? Evidence from Nigeria. Journal Home 2008;12:219-33. |
|7.||Ezeoke OP, Onwujekwe OE, Uzochukwu BS. Towards universal coverage: Examining costs of illness, payment, and coping strategies to different population groups in southeast Nigeria. Am J Trop Med Hyg 2012;86:52-7. |
|8.||Metiboba S. Nigeria′s national health insurance scheme: The need for beneficiary participation. Res J Int Stud 2011;12:51-6. |
|9.||Falkingham J, Akkazieva B, Baschieri A. Trends in out-of-pocket payments for health care in Kyrgyzstan, 2001-2007. Health Policy Plan 2010;25:427-36. |
|10.||Yu CP, Whynes DK, Sach TH. Equity in health care financing: The case of Malaysia. Int J Equity Health 2008;7:15. |
|11.||Zikusooka CM, Kyomuhang R, Orem JN, Tumwine M. Is health care financing in Uganda equitable? Afr Health Sci 2009;9 Suppl 2:S52-8. |
|12.||National Health Insurance Scheme. Guidelines for the Operation of the Formal Sector Social Health Insurance Programme. Abuja: FMOH; 2005. p. 181. |
|13.||Lanre-Abass BA. Poverty and maternal mortality in Nigeria: Towards a more viable ethics of modern medical practice. Int J Equity Health 2008; 7:11. |
|14.||Nkanginieme KE. Medical education in Nigeria. Niger J Med 1998;7:127-32. |
|15.||National Population Commission Nigeria and ORC Macro. Nigeria Demographic and Health Survey. Calverton, Maryland: National Population Commission and ORC Macro; 2008. |
|16.||United Nations Development Programme. The Millennium Development Goals, 2001. Available from http://www.undp.org/mdg, http://www.unmilleniumproject.org/html. [Last accessed on 2014 Mar 14]. |
|17.||Olugbenga-Bello AI, Adebimpe WO. Knowledge and attitude of civil servants in Osun State. Niger: Southwestern Nigeria Towards the National Health Insurance. Niger J Clin Pract 2010;13:4216. |
|18.||Oyibo PG. Out-of-pocket payment for health services: Constraints and implications for government employees in Abakaliki, Ebonyi State, south east Nigeria. Afr Health Sci 2011;11:481-5. |
|19.||Understanding Poverty. Available from: http://www.worldbank.org. [Last accessed on 2014 Mar 13]. |
|20.||Cohen RA, Martinez ME. Consumer-directed health care for persons under 65 years of age with private health insurance: United States, 2007. NCHS Data Brief 2009; (15):1-8. |
|21.||Schoen C, Doty MM, Robertson RH, Collins SR. Affordable Care Act reforms could reduce the number of underinsured US adults by 70 percent. Health Aff (Millwood) 2011;30:1762-71. |
|22.||Mohammed S, Sambo MN, Dong H. Understanding client satisfaction with a health insurance scheme in Nigeria: Factors and enrollees experiences. Health Res Policy Syst 2011;9:20. |
|23.||Fatiregun AA, Ejeckam CC. Determinants of patient delay in seeking treatment among pulmonary tuberculosis cases in a government specialist hospital in Ibadan. Nigeria. Tanzan J Health Res 2010;12:1-8. |
|24.||Park K. Park′s Textbook of Preventive and Social Medicine. 20 th ed. India: Banarsidas Bhanot Publishers; 2009. p. 35-8. |
|25.||Whitehead M, Dahlgren G, Evans T. Equity and health sector reforms: Can low-income countries escape the medical poverty trap? Lancet 2001;358:833-6. |
[Table 1], [Table 2], [Table 3], [Table 4]