The costs of Illness Payment and Coping Nigeria

The negative consequence of unwellness costs on families can be significant particularly in resource hapless scenes and in absence of wellness insurance. This paper examined the costs of unwellness for families belonging to different socio-economic position groups and geographic topographic points of residence. It besides examined mechanisms that the different population groups used to pay for wellness services and how they coped with payments.


The survey took topographic point in Anambra and Enugu provinces southeast Nigeria. It was conducted in three ( 3 ) communities in each province doing up six ( 6 ) communities in entire. These were two urban, two semi-urban and two rural communities. Data was collected from a lower limit of 3000 families ( 500 families from each community ) utilizing a pre-tested questionnaire. Data was collected on incidence of assorted unwellnesss, outgos, payment mechanisms and payment get bying mechanisms utilizing a one month recall period. The information was examined for links between socio-economic position ( SES ) and geographic location with outgos, payment and get bying mechanisms. The SES index was used to split the families into quartiles and chi-square analysis was used to find the relationship of SES and geographic residence of families with cost of unwellness, payment mechanism and header schemes


Malaria was the unwellness that most people had. The mean cost of transit was 86 Naira ( 0.6 US $ ) and the entire cost of intervention was 2819.9 Naira ( 20 US $ ) out of which drug costs entirely contributed more than 90 % . . Out of pocket ( OOP ) was the chief method of payment ( % ) . Peoples largely coped with payment for wellness services utilizing their ain money, merely in few instances were wellness insurance used.


There are high degrees of wellness outgos at the family degree. Risk protection mechanisms are about non-existent. Policy actions should be hence be channeled towards set uping appropriate mechanisms to protect families against the fiscal load of direct wellness attention payments.

Keywords: wellness seeking, cost of unwellness, payment mechanisms, Nigeria


Ill-health impacts well on the economic sustainability of families ( Leive & A ; Xu, 2008 ) , particularly in resource hapless scenes with deficiency of effectual wellness insurance policies. The method of funding health care is linked to household intervention seeking forms ( Asenso-Okyere et Al, 1998 ) and the schemes for get bying with payments can increase a householdaa‚¬a„?s susceptibleness to impoverishment ( Chuma et al, 2007, Whitehead et Al, 2001 ) . The World wellness estimated that families that spend 40 % or more of their non-food outgo on intervention are likely to be impoverished ( WHO 2000 ) . To this consequence, the hapless are likely to be the most affected as they can be pushed farther into deeper degree of poorness because they spend larger proportions of their income than the wealthier group when they seek attention ( Leighton & A ; Foster, 1993 ) . Previous cost of unwellness surveies have shown that for families in low and in-between income states, these costs are often above 10 % of household income ( McIntyre et al, 2006 ) , while costs above this threshold are being regarded as potentially ruinous ( Ranson, 2002 ) , there are statements that any wellness outgo that deters families from ingestion of their basic demands is ruinous and may non basically amount to high wellness attention payments in existent footings ( Van Damme, et al 2004 ) .

In SSA states the load of wellness outgos are largely attributed to common endemic diseases because they constitute a bulk of the public wellness jobs due to their perennial nature and are major causes of morbidity and mortality ( Boutayeb, 2006 ) . Such diseases which include malaria, enteric fever, TB and diarrhoeal disease amongst others are the greatest subscribers of the economic load on both families and authoritiess in Nigeria ( Onwujekwe, 2005 ) , for case an one-year economic loss of 132 billion ( FMOH, 2005 ) an estimated 300,000 deceases each twelvemonth ( FMOH, 2009 ) , 60 % of outpatient visits and 30 % hospitalizations ( NPC, 2008 ) are all attributable to malaria. In add-on, approximately 50 % of the population experience at least one episode of malaria yearly ensuing in high productiveness losingss ( FMOH 2005 ) . Existing hazard protection mechanism in the state is weakened by low coverage of the population and being of user charges hence people pay out of pocket each clip they receive attention which creates unfairnesss in intervention seeking in favour of those with more ability to pay.

Available grounds shows that the heaviest load of wellness attention costs, peculiarly those that are considered ruinous, falls on the poorest ( Xu et al. , 2003 ) . Although the costs of unwellness differ by disease type ( Russell 2004, McIntyre, et al 2006 ) regressive cost loads were found among the poorest families in urban and rural Kenya for all classs of unwellnesss studied ( Chuma et al, 2007 ) . In Nigeria, a high incidence of ruinous wellness outgos was found particularly on the poorest quintiles of the population even at changing threshold degrees ( Onoka et al, 2010 ) . Some writers have besides shown that intervention outgos for malaria most significantly depleted the aggregative income of the two poorest Selenium groups and of the rural inhabitants, lending to more than 20 % of one-year heath outgos, and besides accounted for more than 10 % of monthly family outgo for the poorest socio-economic position ( Onwujekwe et al, 2010 ) .

The costs of unwellness for families frequently leads to unfairnesss in entree to care as the hapless are deterred from the usage of health care therefore forestalling health care services from making those most in demand of it ( Aye, 2010 ) . In Nigeria, out of pocket payments ( OOP ) remain an of import beginning of support for health care with OOP accounting for more than 90 % of private outgos on wellness ( Soyibo et al, 2009 ) . Because these direct payments topographic point immense fiscal load on persons, some families refrain from seeking attention in an effort non to incur cost but the net consequence is frequently that many families incur greater costs on the long tally due to possible complications from unwellnesss which could hold been abated if attention was sought before ( McIntyre, 2007 ) .

Some families are merely able to pull off payments by utilizing get bying schemes that are likely to hold inauspicious effects on their endurance ( Russell, 2004, McIntyre, 2006 ) . The overall frequence of utilizing such schemes has been found to be more common among the poorest states and those with limited wellness insurance ( Kruk et al, 2009 ) . The effects of these schemes really frequently maintain families in debt or poorness for a long period of clip after the unwellness which created the debt ( Acheampong & A ; Gish, 2001 ) .

This paper presents the findings on family costs of unwellness and payment mechanisms and payment header schemes for common unwellnesss in southeast Nigeria. A good cognition of costs and payment methods and how they differ by SES and geographic location of family is of import for implementing equity advancing policies that will assist to cut down the economic load of diseases.


Study country:

The survey took topographic point in Anambra and Enugu provinces southeast Nigeria. Both provinces are lgbo talking with English being widely spoken as the 2nd linguistic communication. The citizens are preponderantly Christians. Anambra province with its capital at Awka has a entire population of 4,182,032 in a land country of 4,416 sq. kilometer, giving an mean denseness of 633 individuals per sq. kilometer ( NPC, 2006 ) . The province is, hence, one of the most dumbly populated provinces in Nigeria. It is bounded in the Northeast by Enugu province, in the E by Enugu and Abia provinces, the West by Delta while in the South and Northwest by Imo and Kogi provinces severally. The province comprises 21 Local Government Areas ( LGAs ) and 177 communities.

The major urban Centres of the province are Onitsha ( 361,574 ) , Nnewi ( 121,065 ) , and Awka ( 58,225 ) . Onitsha is the prime metropolis of the province. It is a fast turning commercial metropolis, with one of the largest markets in West Africa. Nnewi is a quickly developing industrial and commercial Centre. The people of the province are widely known to be really resourceful, hardworking, sociable and suiting. They are extremely enterprising and are reputed for their concern acumen. Skilled manpower resources are readily available in every field of human enterprise ( hypertext transfer protocol: // blurb=193 ) .

Enugu province with its capital in Enugu has seventeen local authorities countries ( LGAs ) in the province, five of which are mostly urban. Enugu State has a population of 3,257,298 within a entire country of 7,618 sq. kilometer ( FGN, 2007 ) . The province has three of import urban Centres: Enugu, Nsukka and Oji River. Enugu is a modern metropolis which covers an country of 85 sq. kilometer. with a population of about 500,000. It is a good developed coal excavation, commercial, fiscal and industrial Centre, with a flourishing economic system and huge investing chances ( hypertext transfer protocol: // blurb=254 ) .

The survey was conducted in three ( 3 ) communities in each province. These were an urban, a peri-urban and a rural community. In Anambra province ; Awka ( urban ) , Amawbia ( peri-urban ) and Amansea ( rural ) were the survey countries. In Enugu province ; Uwani ( urban ) , Iji-Nike ( peri-urban ) and Amokwe ( rural ) were the survey communities.

Study design and survey tools:

A pre-tested interviewer-administered questionnaire was used to roll up information on family wellness seeking behavior from indiscriminately selected homeowners. Information was besides obtained on the costs that people incurred while seeking intervention and the methods of paying for health care.

Household questionnaire sampling

The questionnaire was administered to respondents from a lower limit of 3000 families ( 500 from each community spread over the communities ) selected by simple random trying from a sample frame of families totaling system prepared by the National Bureau of statistics ( NBS ) . Adequate sample size was determined, utilizing a power of 95 % assurance degree and utilization rate of wellness installations of 20 % . The caputs of families or the most senior member of the family from the selected families was interviewed. The interviewers were trained over a period of three hebdomads so as to guarantee their command of the inquiries. Data was collected on the unwellness that the family had one month to the day of the month of the interview the demographic construction and the socioeconomic features of the family. Questions besides addressed the costs that families incurred in seeking intervention one month prior to the interview and payment methods used.

Datas analysis

Tabulations and bivariate analysis were the informations analytical tools. The information was pooled to obtain the informations sets for urban, peri-urban and rural countries. The information was examined for links between socio-economic position ( SES ) and geographic location with the cardinal variables. For specifically analysing the socio-economic and equity deductions of the information from the consumers, an asset-based SES index was created utilizing chief constituents analysis ( Filmer and Pritchett, 2001, Onwujekwe, 2005 ) . Information on family ownership of wireless set, bike, telecasting set, bike, electric refrigerator, every bit good as per capita weekly nutrient value were the variables in the SES index. The first chief constituent was used to deduce weights for the SES index. The SES index was used to split the families into quartiles and chi-square analysis was used to find the statistical significance of the distinction of the dependent variables into SES quartiles. Comparison between the three geographic locations was used to analyze for geographic differences


Demographic features of respondents

Most of the respondents from the six survey communities were male caputs of families, middle-aged, chief income earners and chief determination shapers about family outgos ( Table 1 ) . The tabular array besides shows that the mean figure of family occupants was 5 people in the six survey countries. Majority of the respondents had some formal instruction and the least Numberss of old ages exhausted schooling were found in the two rural communities of Amansea and Amokwe at about 9 old ages in the two communities

The types of unwellness that people had and where they sought intervention

Table 2 shows that malaria was the major unwellness in the communities with the urban communities accounting for the highest proportion of malaria instances ( 61.7 % ) . A considerable figure of people had typhoid with highest happening in the rural communities. Few people in all the communities had diarrhoea.


Travel clip and mean monthly intervention and transit costs for the respondents in the three types of community ( urban, peri-urban and rural )

Peoples on the mean spent about 28 proceedingss to go to the assorted health care suppliers in order to have intervention for their unwellnesss. The travel clip was highest in the rural countries when compared to both the urban and peri-urban countries. Table 3 shows that from the combined information of the 3 types of communities. The mean cost of transit was 86 Naira ( $ 0.6 ) and the entire cost of intervention was 2819.9 Naira ( $ 20 ) . Drug cost was 2191.3 Naira ( $ 16 ) which amounts to more than 90 % of the entire intervention cost. The occupants of peri-urban countries spent more on intervention and drugs compared to the urbanites and rural inhabitants. The consequences were statistically important ( p & lt ; 0.05 ) .

Morbidity from unwellness by SES

The really hapless and the least hapless ( Q2 and Q4 ) spent the highest sum of money on intervention. Transport cost was highest for the least hapless ( Q4 ) followed by the most hapless ( Q1 ) and lowest for the really hapless ( Q2 ) .

There was SES distinction in intervention outgos, where 1821 Naira ( $ 13 ) was the least sum paid on intervention and by the most hapless.

Payment and payment get bying mechanisms

Table 5 shows that the out-of-pocket disbursement ( OOPS ) was the major payment mechanism in all the communities followed distantly by installment. Health insurance was seldom used. Peoples largely coped with payment utilizing their ain money and a few borrowed money to pay, more people in the urban than in the rural country borrowed money to pay for attention. Exemptions, subsidies and recesss were seldom used


This survey found that peri-urban families are more likely to incur higher health care costs than urban and rural families. Besides really hapless families are more likely spend more on intervention which implies that they are at a higher hazard of enduring wants due to ill wellness. Although some writers have opined that other factors such as plus base ( Van Damme et Al, 2004 ) and handiness of societal webs ( Gougde et al. , 2009 ) play a function in finding if a family will be impoverished by wellness outgos or non this paper nevertheless did non gauge if these costs were impoverishing to families.

The determination that malaria ranked highest among the unwellnesss experienced by homeowners is consistent with what has been observed in other surveies in this part ( Uzochukwu & A ; Onwujekwe, 2004, Okeke & A ; Okafor, 2008 ) . A considerable figure of respondents besides suffered from enteric fever and other unwellnesss and if combined with the load of malaria, this could hold important impact on families.

Where wellness attention payments are made largely through OOPs many families face the hazard of being impoverished to illness, although the poorest Selenium paid the least sum on drugs and intervention in this survey, this could intend that they opt for cheaper options or ration their ingestion in order to be able to pay ( Chuma et al, 2007 ) . Other surveies have besides shown that handiness of hard currency is a determiner of what intervention services are consumed and if attention will be sought at all ( Mcintyre et al. , 2006 ) . Where intervention is sought the rural families spend a greater sum of clip in acquiring to a intervention installation as is found in this survey due to the limited figure of formal wellness installations and trained suppliers in these countries, this extra cost of conveyance rises intervention cost and can perchance impact intervention seeking form ( Oaa‚¬a„?Donnell et al. 2005 ) . Outgos on drug besides constituted a major portion of health care payments in this survey, this is non surprising as most people sought attention from patent medical specialty traders where there are largely no signifiers of subsidy for drugs as opposed to the populace sector where certain drugs are subsidized particularly for the vulnerable group.

Peoples largely coped with payments utilizing their ain money and other surveies have reported the sale of plus and farm animal as a manner of get bying with common unwellnesss such as malaria ( Sauerborne et al, 1996 ) . Such mechanisms were non found in this survey, nevertheless more people in the urban than rural countries borrowed money to pay for attention. This should non be taken to intend that rural inhabitants have adequate nest eggs to countervail their health care costs instead it could be because of the possible troubles for people in the rural countries to borrow money because of the absence of loaners or perchance due to miss of their ability to supply collateral for obtaining loan. There is hence an pressing demand to supply some hazard protection to decrease the load direct and indirect costs of unwellness and cut down the incidence of OOP on family


This survey showed that there are high degrees of wellness outgos at the family degree with the really hapless likely to incur higher costs of attention. This could ask the ingestion of lower quality and more inappropriate intervention in order to cut down cost. In recent times, in order to cut down the load of direct wellness payments and increase wellness service use, wellness systems of many states are seeking to travel off from over dependance on out of pocket payments as a beginning of wellness funding towards payment schemes affecting some signifier of hazard pooling ( Bennet & A ; Gilson, 2001 ) . However, the chief challenge to accomplishing this end in many Sub-saharan African ( SSA ) states has been the deficiency of effectual mechanisms to pool hazards.

Of greatest concern is hence the demand to replace the current pattern of healthcare payment through OOPs with other prepayment mechanisms with cross subsidies from the rich to the hapless and from healthy to the wealthy while protecting families against the fiscal load associated with unwellness. This could be achieved through concerted attempts towards the enlargement of the present Nigerian National Health Insurance strategy to cover both the vulnerable group and informal sector while sponsoring and scaling up community based funding mechanisms.