Predictors of health insurance uptake among residents of Lagos, Nigeria

INTRODUCTION Health insurance is a health-financing mechanism to protect people from catastrophic healthcare costs and limits out-of-pocket spending on healthcare, which is directly linked to poverty. This study assesses the extent of health-insurance uptake and associated factors in Lagos, Nigeria. METHODS We conducted a cross-sectional survey of consenting adults residing in Lagos, Nigeria. Participants were enrolled at general outpatient clinics of four public health facilities in Lagos State. Sociodemographic characteristics and data on health-insurance uptake were obtained and grouped into uninsured, National HealthInsurance Scheme (NHIS) and Private Health-Insurance (PHI). Factors associated with health-insurance uptake was determined using chi-squared tests and logistic regression models. Statistical significance was placed at p<0.05. RESULTS A total of 1000 respondents were enrolled in the study. Overall, 9.5% of participants had health-insurance: NHIS (5.6%) and PHI (3.9%). Males had a higher healthinsurance uptake than females (p=0.035). Respondents who were married had higher odds of health-insurance uptake than those that were single (AOR=2.23; 95% CI: 1.20–4.16; p=0.01). Similarly, respondents who had a secondary-school diploma had higher odds of having a health insurance compared to those with less than a secondary-school education (AOR=5.20; 95% CI: 1.14–23.68; p=0.03). CONCLUSIONS Our findings suggest a low rate of healthinsurance uptake in the population. Being male, married and possessing a secondary school diploma or higher were associated with higher odds of health insurance uptake. Policy measures should focus on expanding access to health insurance, particularly among the less educated and the informal employment sector. Research Paper | Population Medicine Popul. Med. 2023;5(July):19 https://doi.org/10.18332/popmed/169666 2 and inequalities3. UHC is a multisectoral issue that requires legislation, budgetary allocations, and regulatory oversight, and it involves several governmental and non-governmental sectors for its implementation. Financing health services is essential to achieving UHC, and health insurance is a critical component of financing options to achieve qualitative healthcare4. In Nigeria, healthcare is funded through different sources; however, current estimates suggest that over 70% of Nigerians still depend on out-of-pocket payments, making it the country’s major source of healthcare financing5. According to the World Bank, out-of-pocket spending on healthcare is directly linked to an increase in the number of people who fall into extreme poverty6. With over 90 million Nigerians living in poverty7, financial protection is crucial so more people are not pushed into extreme poverty due to healthcare costs. The Nigerian government established the National Health Insurance Scheme (NHIS) in response to increased out-ofpocket payments and the call for a movement towards UHC8. Although NHIS started its operation in 2005, as of 2016, less than 5% of the Nigerian population had been enrolled in this program, with higher coverage amongst people in the federal sector, leaving the greater part of the population uninsured9,10. Another source of health financing is private health insurance (PHI) which covers less than 1% of the Nigerian population11. In addition to the NHIS and PHI schemes, state health insurance schemes may also provide citizens with health financing opportunities8,12. Based on the last Demographic and Health Survey in Nigeria, the prevalence of coverage of health insurance was 2.8%, which was very low compared to South Africa, with a prevalence of 13.3%13. Lagos is currently the most populous city in Sub-Saharan Africa, with over 20 million inhabitants, widely distributed in several rural and urban communities. It is a densely populated state and the economic and business hub of Nigeria, with almost half of the commercial activities in the country taking place in the city14. In contrast to other states in Nigeria, Lagos has the highest number of health facilities, including 26 general hospitals and 256 primary health centers managed by the state government, and over 2800 private hospitals, specialist clinics and laboratories15. In 2015, the Lagos state government enacted the Lagos State Health Management Agency Law to guide the establishment of the Lagos State Health Management Agency (LASHMA) to ensure that residents of Lagos State have access to quality healthcare and limit out-of-pocket healthcare spending12. The agency launched the Lagos State Health Insurance Scheme (LSHS)12, which began enrolling users in the third quarter of 2019. Prior to the inauguration of the LSHS, Lagos State inaugurated three Community Based health insurance (CBHI) schemes. At the same time, several of the residents in the state are registered with the National Health Insurance Scheme (NHIS) and private health insurance plans through Health Maintenance Organizations (HMOs)16,17. Inadequate coverage and low uptake have bedeviled these schemes, while both enrollees and providers have expressed dissatisfaction about these arrangements17,18. However, since the inception of LASHMA, there has been a dearth of literature assessing the uptake of health insurance in the state. Data on health insurance coverage before and in the early stages of the agency’s launch can provide baseline information to guide monitoring and evaluation of the scheme to ensure it meets its target of increasing health insurance coverage in the state over time. Surveillance of health insurance uptake is important for planning outreach activities to increase enrollment and access to healthcare financing within the population. Ultimately, these measures can reduce the burden of disease and poverty linked with the high cost of healthcare, especially for the underserved. This study aims to assess the extent of health insurance uptake and factors associated with health insurance uptake in Lagos, Nigeria. Findings from this study will help policymakers identify sociodemographic groups within the population without health insurance coverage in the state and support measures to increase health insurance uptake within the state. METHODS Study design and population This study used a cross-sectional design. Study participants comprised individuals aged ≥18 years residing in Lagos State, Nigeria. A multi-stage sampling method was used, using the list of secondary health facilities in Lagos State, Nigeria, as the sampling frame. The secondary care facilities in the state were utilized because they are the main providers for public sector employees, who were the first set of people to assess the scheme. In the first stage, a simple random technique with ballot papers was used to select four health facilities from the sampling frame of 20 facilities. The selected healthcare facilities were located in urban areas in Lagos State, namely: Lagos Island, Gbagada (Kosofe local government area), Ikeja, and Alimosho, which serve a combined population of 12.6 million people. In the second stage, a simple random sampling method was used to enroll consenting first-time patients attending the general outpatient clinics of the selected health facilities over a period of four weeks (January 2020), utilizing the attendance register as the sampling frame. Two hundred and fifty participants were daily enrolled from the general outpatient clinics in the selected facilities, representing the population in this study. Study measures The instrument was developed from a previously validated measure19. Information was obtained on the age, sex, marital status, education level, and health insurance use among respondents (defined as ‘health insurance uptake’ throughout the article). Health insurance uptake was assessed by asking respondents to select their health Research Paper | Population Medicine Popul. Med. 2023;5(July):19 https://doi.org/10.18332/popmed/169666 3 insurance plan among four options: No insurance, National Health Insurance Scheme (NHIS), Community Based Insurance (CBIS) and Private Insurance (PI). The Lagos State Health Insurance Scheme was excluded, as enrolment had not begun at the time of study design. Statistical analysis Sociodemographic information and health insurance uptake were expressed using descriptive statistics. The association between sociodemographic variables and health insurance uptake was investigated using chi-squared and bivariate logistic regression analysis. A p<0.05 was considered statistically significant, and tests were 2-tailed. Statistical analysis was done using STATA 15.0 software (StataCorp LLC Lakeway Drive, College Station, Texas). RESULTS General description A total of 1000 respondents completed the survey. The mean age of participants was 38.6 ± 15.02 years, with females accounting for 53.4%. Most (53.1%) were married, and 48.1% had a college education or higher (Table 1). Health insurance uptake About 90.5% of the study population had no health insurance plan, while 5.6% were enrolled under the NHIS scheme and 3.9% were enrolled in a PHI scheme. None was enrolled in a CBIS (Table 1). Table 2 shows a chi-squared Continued Table 2. Chi-squared test of independence between sociodemographic factors and health insurance uptake in the study population, residents of Lagos, Nigeria, 2020 (N=1000) Variables No health insurance n (%) Health insurance n (%) Total n p