The Effect Of Poverty And Access To Health-care

In Nigeria the average household expenditure on health care between 1999 and 2001 stood at 64.25%, and rose to 68.45% between 2002 and 2005 while the public expenditure on health care stood at 35.7% and 31.65% during these same periods of timerespectively.1,7 This large percentage (68.4%) contribution by households to health care financing is made up of expenditure by both the majority have-not and a few have-much as there is no disparity between what the rich and poor households pay for health care despite the wide difference in their economic status. There are no specific provisions for healthcare schemes for the poor in the society, most especially for those living in the rural areas where the poor of the poorest are found in their numbers. Even where specific free health care services are made available, such as free immunization scheme or family planning, they are equally enjoyed by the rich and the poor. There is also an irony in the implementation of the social health insurance (National Health Insurance Scheme {NHIS}), where those that are in dire need for the scheme scheduled for the second set of people to be reached for the scheme while those who are economically better-off and therefore most likely able to purchase health care enjoy the privilege of being the first to benefit from this scheme.  Therefore it can be subsumed that poor households are at disadvantaged position of paying disproportionately higher for health care than richer households. 

Some African countries, e.g. Uganda and South Africa have some exemption methods for the terminally ill and people with HIV/AIDS most especially if such a person is the head of a households. Some other countries have special healthcare package(s) such as, exemption from payment for health care for the elderly or delayed payment for those who are incapable of paying at the point of service8-10. This type of package is almost in nonexistence in Nigeria even though the federal government and some states have some forms of free health care service such as immunization, free antenatal and delivery services for the pregnant women and free treatment bill for the under-5 children but, these packages are not exclusively reserved for the poor. 

Low spending on health care by all tiers of government in Nigeria is an important contributor to the high poverty incidence by households. The total government health expenditure (TGHE) as a proportion of the total health expenditure (THE) was estimated to be 18.69% in 2003, 26.4% in 2004 and 26.02% in 2005 while household health expenditure (HHHE) as a proportion of THE was 74.02% in 2003, falling to 65.73% in 2007 but went up to 67.22% in 2005.1 Not only was TGHE low but also that the rate of increase per annum was rather too low and slow. Comparing the Nigeria case to some other African countries such as Zambia, where HHHE was 21.20% of the THE in 2002 while corresponding value for Kenya was 51% and Egypt was 60% in the same year1.It?s evidently clear from this that there is unwillingness on part of Nigeria government to increase its expenditure on health. This apathy may not be peculiar to Nigeria as it has been observed that, there is general apathy among government of developing countries to improve spending on health care. For instance, in 1994 the  global expenditure on health total US $ 2.3 trillion, with high-income countries spending about US $2.0 trillion of this total even though they accounted for only 16% of the world population. Developing nations on the other hand spent only 11% of the total global spending on health but accounted for 84% of the world population.11

This wide gap between developed and developing nations might have been contributed to by the enabling environment and incentives for independent health insurance organizations to participate in health care for its citizens. The level of participation by private insurance institutions in the United Kingdom, USA, and Uganda stood at 55%, 

While in Nigeria, between 2003 and 2005 health insurance contributed at only 3% of the THE. Health insurance is meant to improve access to health care, thus promoting good health. Reasonable access to health care encourages individuals to seek health maintenance services more regularly than they otherwise would, thereby prevent potentially serious illnesses and protect individuals from financial hardship that may result from large or unexpected medical bills.  Health insurance can be obtained from private organizations or from government agencies.6It was in response to the urgent need for health insurance that the Federal Government set up the National Health Insurance whose bill was passed into law in 1999 although it only became operational in 2006. This scheme is intended to be a tool for achieving health related Millennium Development Goals (MDGs) but, the target group are not being reached via this scheme. For example, reduction of infant and maternal mortality rates, those who contribute most to these high rates (poor households) are yet to be reached with the scheme12. Even though there are plans to expand the programme to reach the informal sector and therefore the rural poor, the actualization of this goal is not likely in the immediate feature in view of the rather slow phase of implementation and also for the lack of pre-existing structures, that could serve as the lunch pads for the programme as it was done in Ghana. Ghana started the mandatory health insurance that was introduced as a result of increased request for an alternative health care financing system for its PHCs,  however, prior to this there were informal community and private trials of various health insurance schemes, i.e. by 2003 just before its introduction, there were at least 67 district wide schemes and 189 HMOs ran by communities, schools, churches and NGOs that eventually collapsed into the national health insurance scheme thereby giving it wide range of coverage and reaching the informal sector was made with much ease.13 It could therefore be said with some degree of certainty that community organizations for health are important tool for reaching rural households, and could also play the role of mobilizing contributions in rural communities where formal social security scheme  cannot reach because of the difficulty of assessing and collecting contributions. The community can be very effective in mobilizing material and human resources for the expansion of the national health insurance scheme. 

The alarming  private share of expenditure on health in Nigeria is all more alarming as most of it takes place via non-pooled out of pocket expenditure. This seems to have arisen from limited awareness by communities and groups about the potential impact of prepayment financing which spreads risk and pool fund on issues of health care equity, financial protection and social safety-net improvement.6 

These challenges posed by high poverty incidence on health are likely to get worst in the face of global economic down-turn and the ever increasing poverty in lowincome nations. Poor households without financial protection will also continue to experience diminished access to good health care service. Some may resort to leave the sick untreated or go for low quality health care and when these options fail such household could end-up spending catastrophically and, most of often than-not culminate in further impoverishment of such households.14 Expenditure is said to be catastrophic when household expenditure or contribution to the health care system exceed 40 percent of income remaining after subsistence needs have been met.15 This study was thus conducted with the view to determine the level and incidence of poverty incidence on health care by house-holds in Keffi, a semi-urban community of Nasarawa State, North-central Nigeria.