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

International Journal for Equity in Health

Kara Hanson³  Benjamin Uzochukwu²  Chima Onoka²  Obinna Onwujekwe¹ 

[1] Department of Health Administration and Management, University of Nigeria Enugu-Campus, Enugu;Department of Community Medicine, College of Medicine, University of Nigeria Enugu-Campus, Enugu;Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London

关键词: economic burden;    inequities;    expenditures;    Health seeking;   

Others  :  829518
DOI  :  10.1186/1475-9276-10-50

 received in 2011-08-31, accepted in 2011-11-13,  发布年份 2011

【 摘 要 】

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.

【 授权许可】

   
2011 Onwujekwe et al; licensee BioMed Central Ltd.

【 参考文献 】

• [1]Onwujekwe OE, Chima RI, Okonkwo PO: Economic burden of malaria illness versus that of a combination of all other illnesses: A study in five malaria holo-endemic communities. Health Policy 2000, 54:143-159.
• [2]Chima RI, Goodman CA, Mills A: The Economic Impact of Malaria in Africa: a Critical Review Evidence. Health Policy 2003, 63:1-17.
• [3]Onwujekwe O: Inequities in healthcare seeking in the treatment of communicable endemic diseases in Southeast Nigeria. Social Science and Medicine 2005, 61(2):455-63.
• [4]National Population Commission (NPC) [Nigeria] and ICF Macro: Nigeria Demographic and Health Survey 2008. Abuja, Nigeria: National Population Commission and ICF Macro; 2009.
• [5]Mays GP, Smith SA: Evidence links increases in public health spending to declines in preventable deaths. Health Affairs 2011.
• [6]Soyibo A, Lawanson O, Olaniyan L: National health accounts of Nigeria, 2003-2005. Ibadan: University of Ibadan; 2010.
• [7]Soyibo A, Lawanson O, Olaniyan L: National Health Accounts of Nigeria, 1998-2002. Final report submitted to World Health Organization, Geneva. Ibadan: University of Ibadan; 2005.
• [8]Velenyi E: In pursuit of more and better managed funds: policy options to purchase better health for Nigeria: a feasibility study of the National Health Insurance Scheme of Nigeria. Washington DC: World Bank; 2005.
• [9]Preker AS: Feasibility of Mandatory Health Insurance - Challenges in Health Care Financing. Abuja Flagship Courses, Abuja, The World Bank; 2005.
• [10]Lagarde M, Palmer N: The impact of user fees on health service utilization in low- and middle- income countries: how strong is the evidence? Bulletin of the World Health Organization 2008, 86(11):839-846.
• [11]Uguru NP, Onwujekwe O, Uzochukwu B, Igiliegbe G, Eze S: Inequities in incidence, morbidity and expenditures on prevention and treatment of malaria in southeast Nigeria. BMC International Health and Human Rights 2009, 9:21. BioMed Central Full Text
• [12]Gottret P, Schieber G: Health financing revisited: a practitioner's guide overview. Washington DC: World Bank; 2006.
• [13]Federal Office of Statistics (FOS), 2004: Nigeria Living Standard Survey (NLSS) 2003/2004. Abuja: FOS; 2004.
• [14]Onwujekwe OE, Uzochukwu BSC: Socio-economic and geographic differentials in costs and payment strategies for primary health care services in Southeast Nigeria. Health Policy 2005, 71(3):383-397.
• [15]Onwujekwe O, Hanson K, Uzochukwu BSC: Do poor people use poor quality providers? Evidence from the treatment of presumptive malaria in Nigeria. Tropical Medicine & International Health 2011, 16(9):1087-1098.
• [16]Uzochukwu BSC, Onwujekwe OE, Eze S, Ezuma N, Obikeze EN, Onoka CA: Community based health insurance scheme in Anambra State, Nigeria: an analysis of policy development, implementation and equity effects. London: Consortium for Research on Equitable Health Systems, London School of Hygiene and Tropical Medicine; 2009.
• [17]National Health Insurance Scheme (NHIS): Road map for the implementation of Community-based health insurance scheme in Nigeria. In Consultation on Support to NHIS CBSHIS roll-out in Programme States. Abuja:PPRINN-MNCH/NHIS; 2011.
• [18]STATA manual version 6 (1995 - 1999) Texas: STATA press;
• [19]Filmer D, Pritchett LH: Estimating wealth effects without expenditure data - or tears: an application to educational enrolments in states of India. Demography 2001, 38:115-32.
• [20]Wagstaff A, Van Doorslaer E, Paci P: On the measurement of inequalities in health. Social Science and Medicine 1991, 33:545-557.
• [21]Wagstaff A, Van Doorslaer E, Paci P: Equity in the finance and delivery of health care: some tentative cross-country comparisons. Oxford Review of Economics 1989, 5(1):89-112.
• [22]O'Donnell O, van Doorslaer E, Wagstaff A, Lindelow M: Analysing health equity using household survey data: a guide to techniques and their implementation. Washington DC: World Bank; 2007.
• [23]Jimoh A, Sofola O, Petu A, Okorosobo T: Quantifying the economic burden of malaria in Nigeria using the willingness to pay approach. Cost Eff Resour Alloc 2007, 5:6. BioMed Central Full Text
• [24]Hanson K, Goodman Catherine, Lines Jo, Meek Sylvia, Bradley David, Mills Anne: The Economics of Malaria Control Interventions. In Global Forum for Health Research: Helping Correct the 10/90 GAP. Global Forum for Health Research:Geneva; 2001.
• [25]Onwujekwe O, Ojukwu J, Shu E, Uzochukwu B: Inequities in valuation of benefits, choice of drugs, and mode of payment for malaria treatment services provided by community health workers in Nigeria. Am J Trop Med Hyg 2007, 77(1):16-21.
• [26]Makinen M, Waters H, Rauch M, Almagambetova N, Bitran R, Gilson L, McIntyre D, Pannarunothai S, Prieto AL, Ubilla G, Ram S: Inequalities in health care use and expenditures: empirical data from eight developing countries and countries in transition. Bull World Health Organ 2000, 78(1):55-65.
• [27]Okeke TA, Okeibunor JC: Rural-urban differences in health-seeking for the treatment of childhood malaria in south-east Nigeria. Health Policy 2010, 95(1):62-8.
• [28]Mota RE, Lara AM, Kunkwenzu ED, Lalloo DG: Health seeking behavior after fever onset in a malaria-endemic area of Malawi. Am J Trop Med Hyg 2009, 81(6):935-43.
• [29]Okeke TA, Uzochukwu BS: Improving childhood malaria treatment and referral practices by training patent medicine vendors in rural south-east Nigeria. Malaria Journal 2009, 20(8):260.
• [30]Ichoku H, Fonta W, Onwujekwe O: Incidence and intensity of catastrophic healthcare financing and impoverishment due to out-of-pocket payments in southeast Nigeria. Journal of Insurance and Risk Management 2009, 4(4):47-59.
• [31]Siskou O, Kaitelidou D, Papakonstantinou V, Liaropoulos L: Private health expenditure in the Greek health care system: where truth ends and the myth begins. Health Policy 2008, 88(2-3):282-93.
• [32]Liaropoulos L, Siskou O, Kaitelidou D, Theodorou M, Katostaras T: Informal payments in public hospitals in Greece. Health Policy 2008, 87(1):72-81.
• [33]Onwujekwe O, Ojukwu J, Ezumah N, Uzochukwu B, Dike N, Soludo E: Socio-economic differences in preferences and willingness to pay for different providers of malaria treatment in southeast Nigeria. Am J Trop Med Hyg 2006, 75(3):421-9.
• [34]Goudge J, Russell S, Gilson L, Molyneux C, Hanson K: Editorial: household experiences of ill-health and risk protection measures. Journal of International Development 2009, 21(2):159-168.
• [35]Onwujekwe O, Dike N, Uzochukwu B, Ezeoke O: Informal payments for healthcare: Differences in expenditures from consumers and providers perspectives for treatment of malaria in Nigeria. Health Policy 2010, 96(1):72-79.