KIT Royal Tropical Institute carried out a benefit incidence analysis (BIA) of the ground-breaking Obio Community Health Insurance Scheme in Nigeria, one of Shell’s community health initiatives.  The results of the BIA informed the strategy and scale up of the Obio CHIS programme.

Reducing out-of-pocket healthcare expenditures

The Obio Community Health Insurance Scheme (CHIS) – jointly funded by the Rivers State government in Nigeria and the Shell Petroleum Development Company – aims to reduce out-of-pocket healthcare expenditures of primarily the indigenes and also non-indigenes living in four Shell Industrial Area cluster communities in Rivers State, Nigeria. A BIA was carried out by KIT to determine the extent to which the objectives of the Obio CHIS had been met – where there are gaps in the equitable distribution of subsidies.

Assessing the factors that influence the distribution patterns provides some answers about issues that could be addressed to encourage enrolment into CHIS and increase utilization of services.  A key issue is in understanding what governs health seeking behaviour in the different population groups in order to determine the most relevant interventions.

Quantitative research methods

The study used mainly quantitative methods. Data sources used include: hospital patients’ outpatient/inpatient (OP/IP) records (2012 –2013), hospital financial records (2012- 2013), hospital Monitoring and Evaluation (M&E) records (2012-2013), data set from the Obio CHIS 2nd evaluation survey (2011-2012). Two samples were used: the study sample consisting of 616 hospital folders and the 2nd CHIS evaluation sample comprised of 1005 clients.

Socioeconomic status (SES) categories were calculated using a proxy measure of occupational status of both the patient and his/her spouse’s occupation. To assess whether distribution of benefits was appropriate, benefits were aggregated by socioeconomic group or indigene/non-indigene status and compared to see whether each socioeconomic quintile’s percentage of share of benefits corresponds to their share of the population.

Results

Both of the samples used in the study had similar demographic characteristics and similar distributions of the SES quintiles with proportionately more of the indigenes occupying the poorest quintile. This displays an equitable targeting of the scheme, of the poorest and more vulnerable populations. In terms of utilization of services, general outpatient (GOP) services were found to be pro-poor while Antenatal care (ANC) services were pro-rich; however total outpatient and inpatient services were both weakly regressive (pro-rich) though insignificantly so.

Though the distribution of benefits within the sample was relatively even from the 2nd to 5th quintiles, the poorest quintile had the least benefit with just 12% of the benefits. Furthermore, collectively the poorest 40% of the population had 33% of the benefits. On the other hand, the richest quintile (Q5,) received the greatest share of benefits (23%) when compared to its population share and the richest 40% of the population had over 44% of the benefits. This pattern is driven by the finding that the poor utilize health services less than the richer quintiles.

Other contributors

Another contributor is that the poorest quintile had the highest out-of-pocket (OOP) costs. The indigenes in the study sample also had less health care benefits than the non-indigenes. The indigenes incurred less OOP costs for both OP and IP services compared to the non-indigenes but still had less benefit because of relatively lower utilization of services.

Examining the factors influencing utilization of services: the means (types), time and cost of transportation, showed that the hospital is accessible to those within the four communities and its surrounding areas. The average time of transportation for the clients is well within the range acceptable for Sub-Saharan Africa. However, clients’ time spent per outpatient visit at hospital was too long ranging from 15 to 900 minutes with an average of 308 minutes.

Actions taken

The BIA report acknowledged that it is well documented in literature that the health-seeking behaviour of the poor is usually different from the rich for a variety of reasons and that the poor typically utilize health services less than the rich. This finding was also the case in the Obio CHIS though certain measures had been taken by the CHIS partners to reduce financial and geographical barriers to access – e.g. 50% subsidy of the CHIS premium for the target population (funded by SPDC) and the health facility located within the cluster communities – at a walking distance for the indigenous population.

Further steps were taken, after the challenges identified by the BIA report, aimed at increasing utilization of the scheme and health services by the poor:

1. The CHIS partners ensured that the HMOs employed Community Health Administrators (CHAs) from the local indigenous population to market the scheme and increase awareness and knowledge of the benefits of the CHIS among the target population
2. The CHIS partners used the Lean methodology to address the prolonged waiting time in the health facility. This enabled reduction of the average waiting time from an average of 308 minutes identified by the BIA report to the current average of 120 minutes.

It is of note that when the initial 50% premium subsidy applicable to the indigenes was withdrawn by SPDC, the enrolment was not affected. Equally noteworthy was that one year after the subsidy removal, when the CHIS Board of Trustees approved an increase in the premium from N7200 to N10,000, the enrollment, after an initial drop, later rebounded, increased and surpassed the previous enrolment peak. These observations all point to the sustainability of the scheme.

CNBC Africa broadcasts a 26 min Obio documentary about Obio

A 3 minute version of the film is available on YouTube