The Distribution of Household Health Expenditure in Nigeria: Implications
for Health Care Reform
K.O. Osungbade, Olanrewaju Olaniyan and Saheed O. Olayiwola
[email protected], [email protected], [email protected]
ABSTRACT
Health systems deliver preventive and curative health services which make large impacts on
peoples’ health. Access to these services can lead to individuals spending substantial proportions
of their available income and pushed them into poverty. Due to the negative impacts households
forgo health services and suffer ill health. This study examined the level and distribution of
household health care out of pocket expenditures in rural and urban areas in Nigeria. The results
show that catastrophic health expenditure affects high percentage of people in Nigeria as large
proportion of people spends significant proportion of their non-food expenditure on health care.
It also shows that there is high inequality in the distribution of out of pocket expenditure for
health care as more people in the rural areas are responsible for their medical bills. The study
concluded that Nigerian government needs to take restructuring of health expenses as priority in
her health care reform programme to finds a sustainable health care financing that will reduce the
burden of high out–of-pocket health expenditure and health spending inequality.
1
I INTRODUCTION
Health systems deliver preventive and curative health services which make large impacts on
peoples’ health. However, access to these services can lead to individuals spending substantial
proportions of their available income and pushed some households into poverty. Because of
these negative impacts some households forgo health services and suffer ill health. Health care
financing is a collection of funds from both public and private sources including donor agencies
to pay for services from health care providers. The manner of financing a health system affects
the performance, its functions and the achievement of its goals. The structure of health financing
in Nigeria is made up of public-private mix. The public source comprises public expenditures on
health sector while private financing comprises households and firms’ out-of-pocket
expenditures on health, private health insurance, donor agencies or developments partners’
expenditures on health and health expenditures by departments of private firms. Petu and Soyibo
(2006) observed that the inadequate level of health spending is a reflection of the basic
arithmetic of poverty. Hence, the poverty level in Nigeria being between 60% and 70% of the
population may account for the low level of health spending in Nigeria. In 2005, total health
expenditure (THE) in Nigeria was estimated to be about N976.69 billion out of which a total of
about N656.55 billion (67%) was from households. This scenario is typical of many developing
countries in which direct household spending on health care account for the single largest
component of household spending after food expenditures. With this type of situation there is a
chance of having catastrophic out-of-pocket payment when out of pocket expenditures (OOP)
accounted for about 65% of total payment of health expenditures (Petu and Soyibo, 2006).
Health sector reform was introduced during Structural Adjustment Programme (SAP)
implemented in the 1980s as a result of debt crisis in Nigeria. The economic crisis was evident in
the reduced financial abilities of government to provide social services such as health and
education. The reform includes changing of health financing strategies and reform of public
sector organization and procedures. Governments in most developing countries are facing
increasing pressure to improve the financial sustainability of their health programmes as
international donors have been reducing their presence in many developing countries as a result
of the downturn in the world economy among others. For example the contribution of
Development Partners to health care financing in Nigeria was estimated as N27.87billion (4% of
THE) in 2003 and increased by 29% to N36.04billion (4.6% of THE) in 2004. But it increased
2
by just 1% to N36.30billion (4% of THE) in 2005. Therefore in designing and implementing
policies that affect the cost of health care for households, more needs to be known about the
current structure and financing of the health economy. How much are households currently
spending for health care? What types of services are being utilized? Do the health care utilization
and expenditure patterns of rural households differ from those of urban households? What
percentages of household out-of-pocket funds are spent on private providers, either traditional or
modern? This study examined different types of health services utilized by individuals and the
level and distribution of household health care out of pocket expenditures in rural and urban
areas in Nigeria. In the next section, we review literature on the distribution of health payments
and catastrophic expenditure. Section three examined methodology while section four contains
presentation of results. Section five is pre-occupied with discussion of results and section six
contains conclusion and policy implications of our results on future efforts to design and
implement health care financing reform in Nigeria.
II REVIEW OF THE LITERATURE
Elgazzar et.al (2010) observed that out-of-pocket spending on health care has become a policy
concern for three reasons: first, households may be pushed into poverty as a result of paying
directly for health services; secondly, households facing these health expenses may cut back on
other essential household spending such as food and clothing and thirdly, households may
choose to forgo necessary health care services rather than face the steep financial consequences
thereby creating a vicious cycle of ill health, disability, and poverty. Health policy makers have
long been concerned with protecting people from the possibility that ill health will lead to
catastrophic financial payments and subsequent impoverishment. This has motivated several
examination of the role of households in health care financing in many countries in recent years
using National Health Accounts (NHA) analysis that provides estimates of the sources and uses
of funds in the health sector. Many of these studies had established that households is greater
than previously thought even in countries where health care services are either free or nominally
priced (Berman, 1987). For example estimates of the proportion of out of pocket spending in
Morocco indicated that as much as 41 percent of health care expenditures came from households
74 percent in Burkina Faso (Saurerborn et al. 1995); 55 percent in Egypt (Berman 1997), 67.2
percent in Nigeria as at 2005 (Soyibo et.al, 2009) and nearly half of all health financing in
Middle East and North American Countries comes from private household spending (Elgazzar
et.al, 2010). This predominant of household out of pocket health expenditure in health care
3
funding suggests that socio-economic inequities may exist in health status and the use of health
care services which may creates adverse consequences of ill health.
The burden of out-of-pocket payments on welfare in many countries is related to the cycle of ill
health and economic hardship. Most households that incur high out-of-pocket payments are
usually vulnerable to being plunged into cycle of poverty. These households can be defined as
those that pay greater than an internationally-recognized threshold as a proportion of total
household expenditure which varies between 5 percent and 25 percent of total expenditure, or 15
percent and 40 percent of non-food expenditure (Elgazar et.al, 2010). Several countries have
examined the consequences of paying for health care on households and the accompanying
adverse consequences of ill health have prompted them to expand health insurance coverage
(Elgazar et.al, 2010). The endogenous nature of insurance coverage also makes variations in
health insurance coverage inadequate to account for differences in the incidence of catastrophic
health spending. However, the effect on financial burdens can vary depending on how well
systems work for excluding the poorest households from having to pay fees at the point-of-use.
A deeper consideration of the Nigeria situation reflects that household’s health expenditures
range between 60% and 75% from 1998 to 2005 while public health expenditures on health are
between 15% and 26% as shown in Table 1 (appendix I). Donor agencies and development
partners financing are between 4% and 16% while financing of other departments of private
firms stay around 1% for the whole period while health insurance is mainly from private health
insurance and constitute about 2.4% of total health care financing from 2003-2005. This shows
household incurred higher proportion in the distribution of health expenditure in Nigeria. And it
is an indication of high financial burden on household due to health expenditure in Nigeria and
probable incidence of catastrophic health expenditure.
Studies on the examination of the level and distribution of household health expenditures
between curative and reproductive health care and between rural areas and urban areas are scanty
in developing countries (Parker 1986; Berman et al. 1987; Saurerborn et al. 1996). Available
studies focus only on the public sector despite the fact that policy decisions based only on public
expenditure data can have severe long-term consequences. Since as much as 40-80 percent of
total health expenditures may be excluded from such an analysis in many developing countries,
the government’s ability to affect health practices and expenditure patterns will be severely
4
limited (Newbrander et al. 1994). Comparing reproductive health and curative health in Nigeria;
the 2008 Nigeria Demographic and Health Survey (NDHS) shows that 25.3% of the births were
attended to by midwives, 9.1% by doctors and 19.3% of the women were not attended to by
anyone; possibly because there was no prenatal care services available or inadequate financing
may have deterred the delivery of services. Figure 1 in appendix II shows the percentage of
pregnant women that received prenatal care in Nigeria form 1990 to 2008. The figure shows that
about 63% of pregnant women received antennal care in Nigeria in 1999 and this decline to
about 57% in 2008. Factors identified as a problem in seeking medical care during pregnancy
include getting permission to go for treatment, getting money for treatment; distance to health
facility, transport cost, not wanting to go alone, concern there may not be a female provider or
any health provider and unavailability of drugs.
Malaria was the only curative illness reported in the 2008 NDHS report. Malaria was reported to
accounts for nearly 110 million clinically diagnosed cases per year, 60 percent of outpatient
visits, and 30 percent hospitalizations. Also an estimated 300,000 children die of malaria each
year. It is also believed to contribute up to 11 percent maternal mortality, 25 percent infant
mortality, and 30 percent under-five mortality. In addition to the direct health impact of malaria,
there are also severe social and economic burdens on communities and the country as a whole,
with about 132 billion Naira lost to malaria annually in the form of treatment costs, prevention,
loss of work time, etc. (NPC and ICF Macro, 2009). The use of insecticide-treated nets (ITNs) or
long-lasting insecticidal nets (LLINs) was the main method of malaria prevention employed in
Nigeria. The 2008 NDHS results indicate that 17 percent of households in Nigeria own a
mosquito net (treated or untreated), and 8 percent of households own more than one mosquito
net. Sixteen percent of households own at least one ever-treated mosquito net, and 7 percent own
more than one ever treated mosquito net. By residence, more rural households (19 percent) than
urban households (14 percent) own at least one mosquito net. The percentage of households that
own any mosquito net in the Northern zones ranges from 16 percent to 28 percent, while in the
Southern zones, net ownership ranges from 11 percent to 17 percent. However, ownership of
ITNs is higher among households in the Southern zones. Furthermore, ownership of mosquito
nets and ever-treated nets decreases with increasing wealth quintile whereas ownership of ITNs
increases with wealth quintile.
Concern over health care payments is that households do not have to spend a specific percentage
of their income on health care payments above a threshold classified as catastrophic. The
5
distribution of health expenditure between government payment and household out-of-pocket
payment in Nigeria shows a high percentage of household out-of-pocket payment which may
absorbs a larger share of a poor household’s income and thereby leads to reduction in
consumption of other essential goods and financial impoverishment. This may lead to a decline
in the living standards of the households involved and further drive households into poverty. In
several countries more than 1% of all households spent half or more of their non-food
expenditure on health care. The poverty impact of this can be measured by the change in the
poverty head count (i.e. the proportion of the population in poverty), or the change in the poverty
gap (i.e. the average shortfall from the poverty line) induced by health care payments. Reform in
health care is part of a wider process of social and political restructuring in many countries. In
many countries, health care reforms are part of an overall social transformation and not just finetuning an isolated sector. Countries that have a greater reliance on out-of pocket health care
expenditure tend also to have a higher proportion of households with catastrophic expenditures
which pushes many into poverty and impoverishment. The dominant of out-of-pocket payments
in health care expenditure in Nigeria and its impacts on household welfare required that health
care financing reforms should moved more to risk-pooling financing system.
III METHODOLOGY DATA REQUIREMENT AND ESTIMATION PROCEDURE
Economic theory suggests that financial protection through public or private health insurance
substantially reduces the amount that people pay directly for medical care but the burden of outof-pocket spending can still create barriers to health care access and use. Therefore households
that have difficulties paying medical bills may delay or forgo needed health care (Hoffman et al.,
2005 in Banthin et al., 2008). Contrary to publicly-funded care, out-of-pocket payments rely on
the ability to pay. If the financing of health care is unevenly distributed that it becomes more
dependent on out-of-pocket payments, its burden is, in theory, shifted towards those who use
services more, and possibly from high to low income earners, where health care needs are higher.
The burden of out-of-pocket health spending can be measured either by its share of total
household income or its share of total household consumption. Persons who are older or with
lower incomes tend to have greater levels of illness and are more likely to need health care, so it
is important to determine whether the distribution of out-of-pocket spending varies across the
population.
The data for the study was extracted from 2010 Nigerian Living Standard Survey (NLSS). The
2010 NLSS covered data on demography, health and fertility behaviour, education and
6
skills/training, housing and housing condition, social capital, agriculture, household income,
consumption and expenditure. It gives an account of social and some economic factors of
households across the nation, and provides information based on gender. The survey covered all
36 States of the Federation and the Federal Capital Territory (FCT). The overall concern of the
study was to generate detailed, multi-sector and policy relevant data through welfare and
expenditure approach.
Descriptive analysis is employ to understand the distribution of usage of health facilities for
reproductive and curative health services and the level and distribution of health expenditures
among different population groups in Nigeria. Household non-food expenditure is a proxy
measure of household’s capacity to pay for reproductive and curative health care services. The
share of health care expenditure in non-food expenditure (Zj) is derived as:
Zj = Hexp / NFexp*100
(1)
Where Zj is the share of health expenditure in non-food expenditure, Hexp is the average
household monthly expenditure on health; NFexp is the average household monthly non-food
expenditure. Health expenditure is catastrophic if a household’s health expenditure exceeds 40%
of income remaining after subsistence needs have been met. Lorenz curve was used to show the
inequality in household out-of-pocket health expenditures in Nigeria, by geographical zones, by
sector and by household head.
IV PRESENTATION OF THE RESULTS
Findings from the empirical analysis are presented in this section. Table 1 shows the summary
statistics of the variables employed in the analysis for estimation. The table shows that about
22% of the people lives in urban areas while about 77% lives in rural areas. An average of 117
individuals reported to have been ill for an average of five days in both rural and urban areas.
The result further shows that about 19% of people who reported ill went for consultation with a
consultation fees ranges between N0 and N19, 000. Also about 19% of the respondent reported
to have been admitted to the hospitals or health centre with an average admission fee of about
N2, 369. The average out of pocket expenditure is about N113 with a maximum value of N180,
208. On reproductive health care; about 15% of the respondents have attended antenatal care
with average antenatal fee of about N467.60k. The average non-food expenditure was about N2,
621.68k and average income was about N29, 922.5k while the average health expenditure was
7
about N3, 386. The average share of health expenditure in non-food expenditure was about N229
and those who spend about 40% of their non-food expenditure on health were about 99%. This
shows that the proportion of people spending significant amount of their non-food expenditure
on health were high in Nigeria and the percentage spent were also high that it can put many into
impoverishment.
Table 1: Summary Statistics of the Variables used for Estimation
Variables
Obs
Mean
Std. Dev.
Urban
Rural
People Ill
Days Ill
Consultation
CONSULTFEES
Admission
ADMINFEES
PurchMed
OOP
ANTENATAL
ANTEFEES
NONFDEXP
INCOME
HEXPD
HXPNFDXP
FOURTYNFDX
909342
909342
908693
132221
908693
909342
908693
909342
908693
909342
8959
909342
909342
899358
909342
907955
909342
0.2285037
0.7714963
1.170097
4.831577
1.900285
435.1488
1.987331
2369.697
1.784489
113.651
1.53276
467.5879
2621.679
29922.47
3386.084
229.0826
0.9999648
0.419869
0.419869
0.4441597
3.472082
0.2996193
295.2848
0.1118403
739.197
0.4111763
608.1602
0.4989535
55.36659
22467.48
818264.2
1076.842
2125.427
0.005932
Min
Max
0
0
1
0
1
0
1
0
1
0
1
0
0
0
435.1488
0.0051322
0
1
1
4
14
2
19000
2
120000
2
180208
2
30000
9110921
1.00e+08
183480.4
338608.4
1
Health expenditure is catastrophic if a household’s health expenditure exceeds 40% of remaining
income after food expenditure has been met. The results in table 2 shows that about 77.2% of
rural resident suffered catastrophic health expenditure while about 29.8% of urban resident has
catastrophic health expenditure. This shows that more than proportionate percentage of people in
both rural and urban areas in Nigeria have problem of catastrophic health expenditure. The
implication of this is that the uneven distribution of health expenditure towards out-of-pocket
payment put many into poverty and hindered their access to adequate health care.
Table 2: Percentage of People with catastrophic Health Expenditure
Sector
Total
Urban
%
Rural
%
84.4 32
No
5
15.6
27
Yes
207,783
22.9 701,527 77.1 909,310
Total
207,788
701,554
909,342
8
DISTRIBUTION OF HOUSEHOLD OUT OF POCKET HEALTH EXPENDITURE
The distribution of household out-of-pocket health expenditure is examined by geo-political
zone, sector and household head. From table 3, Both South-East and South-South have the
highest mean health expenditure with N56, 381.24 and N41, 230.62 while North Central and
South West have the lowest mean health expenditure with N22, 024.01 and N22, 392.7
respectively. However, North East and North West have N25, 027.57 and N27, 813.04 as
average health expenditure. This analysis shows that health expenditure is high in Southern
Nigeria compare to Northern Nigeria. It means that out-of-pocket health payment is unevenly
distributed in Nigeria with South-East and South–South having the highest out-of-pocket health
payment and North- Central and South-West with the lowest out-of-pocket health payment.
Table 3: Mean Distribution of Out-of-Pocket Health Expenditure by Geo-Political Zone
Geo-Political Zones
Out-of-Pocket Health Expenditure (NMean)
22,024.01
North Central
25, 027.57
North East
27, 813.04
North West
56, 381.24
South East
41, 230.62
South South
22, 392.7
South West
The distribution of household out-pocket health expenditure by sector in table 4 shows that rural
area have the highest average out-of-pocket health expenditure with N32, 047.58 while the
average out-of-pocket health expenditure in urban area is N29, 223.22. This shows that
individuals in rural area spend more on average on health care services compared to their
counterpart in urban area. Since income of rural inhabitants are lower than their urban
counterpart, it means that rural inhabitants are more likely to be put into poverty by high health
spending and also suffer more from ill health.
Table 4: Mean Distribution of Out-of-Pocket Health Expenditure by Sector
Sectors
Health Expenditure (NMean)
29, 223.22
Urban
32, 047.58
Rural
Table 5 shows the distribution of health expenditure by household head. It shows that a male
headed household on the average spend relatively more on health care services than female
headed households. The average health expenditure in a male headed household is around N31,
726.48 and N31, 211.54 in a female headed household.
9
Table 5: Mean Distribution of Out-of-Pocket Health Expenditure by Household Head
Household Head
Health Expenditure (NMean)
31, 726.48
Male
31, 211.54
Female
0
.2
.4
.6
.8
1
Figure 2: Lorenz Curve of Inequality in Health Expenditure in Nigeria
0
.2
.4
.6
Lorenz (inhlthx)
10
.8
equality
1
0
5000
10000
15000
Figure 3: Lorenz Curve of Inequality in Health Expenditure in Nigeria by Zone
0
.2
.4
.6
Cumulative population proportion
.8
1
0
5000
10000
15000
Fig 4: Lorenz Curve Inequality in Health Expenditure in Nigeria by Sector
0
.2
.4
.6
Cumulative population proportion
11
.8
1
0
5000
10000
15000
Fig 5: Lorenz Curve of Inequality in Health Expenditure in Nigeria by Household Head
.2
.4
.6
.8
Cumulative population proportion
headmale==0
1
headmale==1
Figures 2-5 are Lorenz curves to further shows the inequality in the distribution of household
out-of-pocket health expenditures. Figure 2 shows Lorenz curve for the distribution of household
out-of-pocket health expenditures in Nigeria. Usually the closer the Lorenz curve to the 45degree line, the more equal the distribution of health expenditure among the population; the
greater the degree of inequality, the greater the bend and the closer the Lorenz curve to the
bottom horizontal axis. As can be seen from figure 2, Nigeria has a much more unequal
distribution of household out-of-pocket health expenditure among the total population. Figures 35 also reveals this based on geographical zone, sector and household head, the inequality in
household out-of-pocket health expenditure is also high. This implication of this is that large
proportion of people in Nigeria are likely to be more impoverished due to high percentage of
their non-food expenditure spent on health care services. Therefore, health sector reform in
Nigeria needs to not only address the unequal distribution of health payments between
government and household but must also address closing the gap of out-of-pocket health
expenditure between rural and urban people and between the geo-political zones in Nigeria.
12
V DISCUSSION OF RESULTS
The results of the empirical analysis show myriads of situations. The results show that more than
70% of rural residence self-financed their medical expenses while just about 30% of urban
residences were responsible for their medical expenses. Federal or state government was
responsible for the medical expenses of the large proportion of the urban compare to the rural
people. This shows inequality in health financing among rural and urban residence. Both rural
resident and urban resident suffered from catastrophic health expenditure as large proportions of
them have their health expenditure exceeding 40% of their income remaining after food
expenditure have been met. The Lorenz curves further shows a high degree of inequality in outof-pocket health expenses in Nigeria, between geographical zones and between rural and urban
residents. The results reflect that more than proportionate Nigerians suffered from catastrophic
health expenditure and this may account among others for the high level of poverty in Nigeria.
VI CONCLUSION AND POLICY IMPLICATIONS
The results of the analysis suggest that catastrophic health expenditure is a serious issue in
Nigeria as large proportion of people spends significant proportion of their non-food expenditure
on health care. It also suggests that there is inequality in the distribution of out of pocket
expenditure for health care as more people in the rural areas are responsible for their medical
bills. We concluded that Nigerian government needs to take restructuring of health expenses as
priority in her health care reform programme. Finding a sustainable health financing means is
sine-qua-non for any meaningful reform to take place in the health care sector. Since health
insurance appears to be receiving an appreciable acceptance; government may further explored
this in financing health care in Nigeria to further reduce the burden of high out –of–pocket health
expenditure and health spending inequality.
13
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14
APPENDIX I
Table I: Structure of Health Care Financing in Nigeria: 1998-2005 (NM)
Years
Public Health
Expenditure
Out-of-Pocket Payments
Health Insurance
Households
Socia
%
Firms
%
%
l
All other Private Means
Private
%
Firms
%
Donor
Agencies/Develo
pments Partners
%
Total
%
1998
23,502.13
14.9
108720.00
69.3
2808.95
1.8
-
-
-
-
20,551.00
13.1
1,499.09
0.9
157081.10
1999
2000
29,882.85
40,391.25
16.6
18.8
118,782.39
129,872.07
66.0
60.4
4,283.81
7,238.05
2.4
3.4
-
-
-
-
24,911.96
34,899.04
13.8
16.2
2,030.15
2,808.72
1.1
1.3
179,891.16
215,209.13
2001
69,765.96
27.2
157,601.66
61.5
4.5
-
-
-
-
14,269.05
5.6
3,190.09
1.3
256,283.42
2002
60,211.87
21.6
183,598.37
65.9
4.9
-
-
-
-
17,104.00
6.1
3,981.52
1.4
278,732.15
2003
123,681.78
18.7
489,464.57
74.0
11,456.6
6
13,836.3
9
1,504.07
0.2
-
-
15,655.5
2.4
27,872.16
4.2
3,484.03
0.5
661,662.16
2004
208,207.86
26.4
518,070.34
65.7
1,591.97
0.2
-
-
18,788.9
2.4
36,037.98
4.6
6,026.79
0.8
788,723.91
2005
254,174.42
26.0
656,115.84
67.2
2,016.17
0.2
-
-
21,335.4
2.2
36,296.70
3.7
6,749.09
0.7
976,687.60
Source: Soyibo et.al, 2009.
APPENDIX II
Source: NPC, 2009
15