Asian Journal of Research in Medical and Pharmaceutical

Sciences

4(3): 1-8, 2018; Article no.AJRIMPS.42839

ISSN: 2457-0745

Awareness and Willingness to Participate in

Community Based Health Insurance among
Artisans in Abakaliki, Southeast Nigeria
B. N. Azuogu1* and N. C. Eze1
1
Department of Community Medicine, Federal Teaching Hospital Abakaliki, Ebonyi State, Nigeria.

Authors’ contributions

This work was carried out in collaboration between both authors. Author BNA designed the study,
wrote the protocol and managed the analyses of the study. Author NCE performed the statistical
analysis, managed the literature searches and wrote the first draft of the manuscript. Both authors
read and approved the final manuscript.

Article Information

DOI: 10.9734/AJRIMPS/2018/42839
Editor(s):
(1) Somdet Srichairatanakool, Professor, Department of Biochemistry, Faculty of Medicine, Chiang Mai University, Chiang Mai
50200, Thailand.
Reviewers:
(1) Win Myint Oo, SEGi University, Malaysia.
(2) Cleopatra Ibukun, Obafemi Awolowo University, Nigeria.
(3) Matthew Idowu Olatubi, Bowen University, Nigeria.
Complete Peer review History: http://www.sciencedomain.org/review-history/25837

Received 27th May 2018

th
Accepted 4 August 2018
Original Research Article
Published 10th August 2018

ABSTRACT

Background: Health insurance (HI) is a social security system that serves as a financial risk
protection for families and small businesses, and also increases access to priority health services.
This study determined awareness and willingness to participate in Community Based Health
Insurance (CHBI) Scheme by Artisans in Abakaliki, Southeast Nigeria.
Materials and Methods: Descriptive cross-sectional survey of 380 artisans in Abakaliki was
carried out. Respondents were selected using a stratified systematic random sampling method to
cover all the specialties. Research instrument was semi structured interviewer administered pre
tested questionnaire. Data was analysed using the SPSS software. Chi‑squared test was used for
association at significance level of 5%.
Results: Mean age of the artisans was 31.3 ± 10.3 years and mean income was N15277.
Generally, only 28.7% of respondents were aware of health insurance, out of which 3.9% were

_____________________________________________________________________________________________________

*Corresponding author: E-mail: bnazuogu@gmail.com;

 Azuogu and Eze; AJRIMPS, 4(3): 1-8, 2018; Article no.AJRIMPS.42839

aware of CBHI. Only 5.8% of the artisans had been on any form of Health Insurance, of which
95.5% were on the National Health Insurance Scheme (NHIS). Merely 2.9% of the artisans were
currently enrolled in CBHI. Most of the respondents (78.9%) were willing to participate (WTP) in
CBHI with their preferred organizer being government (77.5%). Majority of respondents were willing
to pay premiums ranging from N400 (91.7%) to N1500 (64.6%) for health services that include
surgery and hospitalization. There was statistically significant association between WTP in health
insurance and educational status (p = 0.002).
Conclusion: The artisans had very low awareness of health insurance but majority indicated
willingness to participate and pay in a Government-backed well organised Scheme. Aggressive
stakeholders’ enlightenment campaign is therefore imperative to increase their awareness.

Keywords: Awareness; willingness; participate; community based; health insurance; Abakaliki.

1. INTRODUCTION CBHIS among artisans (an informal sector) in

Healthcare delivery remains one of the most
important basic social services any government
or organisation can render to its people. Public
health system in Nigeria is characterised by low
funding, poor motivation of health workers and
1
inequitable access to health . Reliance on out-of-
pocket payment for healthcare may lead to
catastrophic health expenditure especially for
poor households and those in informal sector. In
order to mitigate ruinous health expenditures,
risk-pooling mechanisms have been
recommended for people in Nigeria [1].
Community-based Health Insurance Schemes
(CBHIS) attempt to bridge the gap between
increasing health needs and scarce resources in
poor communities, as well as providing protection
for the most vulnerable groups through cross-
subsidization. However, these schemes are often
initiated without strong empirical information that
can help to benchmark cost-sharing potentials
and other forms of participation of households in
the community.
Some studies have reported varying levels of
willingness to pay (WTP) for a CBHIS; as
evidenced by WTP of between 3.6% - 38%
among their respondents in the South eastern
part of Nigeria [1], while that in the South western
part reported a WTP of 82.4% among artisans
[2]. Similar studies in Ethiopia and Bangladeshi
reported WTP by 78% [3] and 86.7% [4] of the
respondents, respectively. Age, gender,
socioeconomic status and place of residence
were identified as determinants of WTP in
previous studies [1,2].
There is plan to strengthen the informal
sector health insurance in Nigeria, and this study
was undertaken to determine the level of
awareness and willingness to participate in a
Abakaliki.
2. MATERIALS AND METHODS
This was a descriptive cross sectional study
carried out among the Artisans in Abakaliki,
Southeast Nigeria. Common artisan groups
include automobile mechanics, electricians,
welders, fashion designers, carpenters and
painters. The various artisans exist as registered
associations, and members pay monthly dues to
guarantee their welfare and support from the
group. This forms the basis upon which they
could also protect and promote their health and
that of their families. Artisans not registered
with any association were excluded from this
study.
A minimum sample size of 380 was calculated
using the Leslie Fischer's formula [5]: n= Z2
2
pq/d , with normal deviate Z=1.96, p=50%,
d=0.05, and confidence interval set at 95%.
Using multi-stage sampling technique the
artisans were initially stratified into their various
groups and a proportionate number of
questionnaires was allocated to each group.
During their monthly meetings the respondents
were selected by systematic random sampling
method using their attendance list as sampling
frame and sampling interval of three. The first
respondent was selected by balloting (from 1 to
3) and others were consecutively recruited until
the list was exhausted. Non-consenting members
were replaced by the same process.
Research instrument was semi structured
interviewer administered questionnaire, which
was pre tested among artisans in another local
government area of the State. Study variables
included socio-demographic data, awareness of
CBHIS and willingness to participate in the
scheme.

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 Azuogu and Eze; AJRIMPS, 4(3): 1-8, 2018; Article no.AJRIMPS.42839
Contingent valuation method (CVM) was used to
measure WTP for health insurance because it
has advantage of face-to-face contact which
reduces misunderstanding and could make
spontaneous questions possible, unlike discrete
choice experiment (DCE) that lacks direct
valuation question [6]. CVM also has a
stronger theoretical underpinning in welfare
economics.
This method had previously been used in
another study [7]. CVM questions can be either
open-ended or discrete. In an open ended
valuation the respondents were asked to state
their maximum WTP for the benefit, typically
using the so called “bidding game”. A bidding
game resembles an auction, where a first bid is
made to a respondent who then either accepts or
rejects. Depending on the answer, the bid is then
adjusted until the respondent’s maximum WTP is
reached. This bidding game approach was
applied to estimate WTP for health insurance.
The "bidding game" has recently been employed
by several studies to estimate WTP for CBHI in
low and middle-income countries [7,8]. To
determine appropriate starting bids, we
interviewed numerous workers from each
occupational group regarding appropriate prices
for CBHI. Based on the interview results a range
was set, and random figures in this range were
included in individual questionnaires as the
starting bids.
The bidding game format used in this study was
modified such that participants will have many
bidding iterations that mimic price-taking in
markets in south-east Nigeria, to enable the most
valid WTP estimate be elicited [8].
The bidding game iteration for payment of
monthly premium used in the study was as
follows:
1. What is the minimum amount you are
willing to contribute for the CBHI? [ ]
(Interviewer: if more or equal to ₦400) go
to Q2)
2. What if the cost of CBHI is ₦1200 will you
be willing to contribute? 1=yes [ ], 0=no [ ]
(no matter the answer, go to Q3)
3. What really is the maximum amount you
are willing to contribute for the CBHI [ ] (If
more or equal to ₦1500 go to Q5, but if
less than ₦1500 go to Q4)
4. The amount that you have quoted is too
low, and cannot cover the cost of the
services, and so you will have to
3
increase the amount if you really want to
participate. So what is the final maximum
amount you are willing to pay per month to
participate? [₦ ]. (No matter the answer, go
to Q5).
5. If due to inflation or other uncertainties, the
cost of participation increased, what is the
maximum amount you are very certain to
pay bearing in mind your average monthly
household income and money you spend
on various items? [ ₦ ].
Three trained research assistants were
employed for data collection. The questionnaire
was also translated into the local language
for clarity of its contents and back translation was
done by two independent experts. Ethical
approval was obtained from Federal
Teaching Hospital, Abakaliki, while written
informed consent was obtained from
individual participants with assurance of
confidentiality.
Data obtained was validated by double entry and
random checks. Data was analyzed using the
SPSS software version 22. Frequency tables
were generated and relevant summary
statistics computed. Chi-squared test of
association was used with the level of
significance at p<0.05.
3. RESULTS
Predictor variables are shown in Table 1. Table 2
showed that mean age with standard deviation of
the artisans was 31.3 ± 10.3 years, and the
mean income was ₦15277. Table 3 showed that
generally, only 28.7% of respondents were
aware of health insurance of which 3.9% were
aware of CBHI. Total of 5.8% artisans had been
on any form of Health Insurance, of which 95.5%
were on the National Health Insurance Scheme
(NHIS) while 4.5% were on retainer-ship. Only 11
(2.9%) of the respondents were currently
enrolled in Community Based Health Insurance.
Table 4 showed that most of the respondents
(78.9%) were willing to participate (WTP) in
Community Based Health Insurance with
preferred organizer being the government
(77.5%). Majority of respondents were willing to
pay premiums ranging from ₦400 (91.7%) to
₦1500 (64.6%) for health services that include
surgery and hospitalization. There was
statistically significant association between WTP
in health insurance and educational status
(p=0.002).
 Azuogu and Eze; AJRIMPS, 4(3): 1-8, 2018; Article no.AJRIMPS.42839

Table 1. Description of predictor variables hypothesized to explain willingness to pay (WTP)

for CBHI

Variables Explanations Measurement Hypothesized relationship

with WTP for CBHI
Age of How old (in years) the A continuous The older the respondent,
respondent respondents are quantitative the less the WTP
Measurement
Relationship Whether respondents 1=have a spouse Respondents with spouses
status of have a spouse 0=do not have a will
respondent spouse have higher WTP than
others
Gender Whether respondents are 1=male Males will have higher WTP
male or female 0=female than Females
Educational Whether respondents had 1=had formal People with formal education
level formal education education will
0=had no formal have higher WTP than
education others
Average Average monthly income A continuous The higher the income the
monthly income of respondent from all quantitative higher the WTP
of respondent sources Measurement

Table 2. Socio-demographic characteristics of respondents (N=380)

Variables Frequency, n (%)

Age group (yrs)
15-25 38 (10)
26-35 128 (33.7)
36-45 112 (29.5)
>45 102 (26.8)
Mean age and standard deviation 31.3 ± 10.3
Gender
Male 292 (76.8)
Female 88 (23.2)
Marital Status
Single 101 (26.6)
Ever married 279 (73.4)
Educational Status
No formal education 10 (2.6)
Primary 39 (10.3)
Secondary 260 (68.4)
Tertiary 71 (18.7)
Job designation
Auto-mechanic 133 (35.0)
Electrician 53 (13.9)
Welder 27 (7.1)
Painter 24 (6.3)
Carpenter 81 (21.4)
Fashion designer 48 (12.6)
Others 14 (3.7)

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 Azuogu and Eze; AJRIMPS, 4(3): 1-8, 2018; Article no.AJRIMPS.42839
Table 3. Respondents’ awareness of community based health insurance (CBHI)
Variables
Ever heard of health insurance before
Yes
No
Ever been on any form of health insurance (n=380)
Yes
No
Type of health insurance (n = 22)
Retainer ship at work place
National Health Insurance Scheme
Ever heard of Community Based Health Insurance
Yes
No
Currently enrolled in Community Based Health Insurance
Yes
No
4. DISCUSSION
Many countries have adopted the National
Health Insurance Scheme option of health care
financing, as a way of addressing the gross
inequity in health care system which may result
from unequal distribution of wealth in societies
[9]. Health insurance as a complementary or
alternative source of health care financing has
become important in the developing world. It has
been implemented as part of health reform
programmes and strategies aimed towards
providing effective and efficient health care for
citizens, most especially for the poor and
vulnerable.
Less than one third of the respondents in this
study had heard of health insurance before, but
only very few of the artisans had been on some
forms of Health Insurance in the past. This
finding is at variance with that found in another
study in which two thirds were aware of NHIS
and only very few had benefited from NHIS [10].
Though the National Health Insurance Scheme
was introduced in Nigeria in 2005, self-employed
workers in the informal sector have had little or no
involvement in the scheme [11]. The respondents
in the previous study were civil servants who are
part of the formal sector Scheme in Nigeria and
this could account for the higher level of
awareness recorded among them. In addition,
the civil servants are most likely to be more
educated than the artisans, and educational
status had significant effect on WTP in health
insurance in this study.
The finding that only few of the respondents had
heard of community health insurance before, with
5
Percentage, n (%)
109 (28.7)
271 (71.3)
22 (5.8)
358 (94.2)
1 (4.5)
21 (95.5)
15 (3.9)
365 (96.1)
11 (2.9)
369 (97.1)
very low proportion enrolled in a form of
Community Health Insurance is similar to another
Nigerian study in which majority of respondents
were neither aware of CBHIS nor took part in the
scheme [1]. The CBHIS in Nigeria is new
concept in its initial stage and this may explain
the low awareness and participation generally in
the scheme especially by the artisans. However,
in Nigerian context, uncertainties as regards the
workability of the scheme under the control of
communities and private sectors as opposed to
government controlled NHIS had led to some
reservations about its authenticity and
functionality. Many CBHIS schemes are bound to
fail if not properly managed. Issues such as weak
management system, poor quality of government
health services, and the limited resources that
local population can mobilize to finance health
care can undermine their success.
However, CBHIS could reduce out-of-pocket
expenditure and improve cost recovery if
properly managed. It appears to be the most
appropriate insurance model for the informal
sector where incomes are unstable. This may
explain the findings from this study where
majority of the artisans showed willingness to
participate in the scheme if government
organizes it than an individual or group of
people. This is in agreement with findings of
other studies in Nigeria [11,12] and India
[13] where most of the respondents were
willing to participate in the scheme.
The enthusiastic disposition of most respondents
to participate is a positive finding that
could foretell the programme success in that
area. However its translation to actual enrollment
can only be demonstrated during proper
intervention and enrollment programme. For
 Azuogu and Eze; AJRIMPS, 4(3): 1-8, 2018; Article no.AJRIMPS.42839

Table 4. Distribution of respondents willingness to participate (WTP) in CBHI

Variables WTP in CBHI (%) χ2 p-value

Yes No
Age group (yrs)
15-25 31 (81.6) 7 (18.4) 4.86 0.18
26-35 119 (92.9) 9 (7.1)
36-45 101 (90.2) 11 (9.8)
>45 94 (92.2) 8 (7.8)
Gender
Male 247 (84.6) 45 (15.4) 0.60 0.43
Female 78 (88.6) 10 (11.4)
Educational Status
None 8 (80.0) 2 (20.0) 15.2 0.002
Primary 31 (79.5) 8 (20.5)
Secondary 248 (95.4) 12 (4.6)
Tertiary 64 (90.1) 7 (9.9)
Income per month (in Naira, ₦)
Less than 15,000 146 (89.6) 17 (10.4) 6.32 0.17
15,000 – 24,999 98 (88.3) 13 (11.7)
25,000 – 34,999 35 (79.5) 9 (20.5)
35,000 – 44,999 28 (80.0) 7 (20)
50,000 and above 21 (77.8) 6 (22.2)
Mean income ₦15277
Willing to enroll self in CBHI
291 (78.9) 78 (21.1)
Willing to enroll family members
280 (96.2) 11 (3.8)
Reason for not willing to enroll in CBHI Scheme (n=78)
No trust in insurance 15 (19.2)
Just not interested 18 (23.1)
Money is lost if not sick 45 (57.7)
Preferred organizer of the Scheme (n = 369)
Community 83 (22.5)
Government 286 (77.5)
Preferred services to be covered by CBHI (multiple choice)
Out-patient services 204
Antenatal clinic and delivery services 177
In-patient care 143
Minor surgeries 152
Major surgeries 189
Premium Respondents are Willing to 400 -1500, ₦15277 ± 0.78
Pay (Range; Mean, Median) ₦13157

those unwilling to participate, the main reason premium costs for the poor and those in informal
given was that money will be lost if one does not sector.
become sick. Community Based Health
Insurance Scheme should be regarded as a This study found that most of the
complement to, not as a substitute for strong respondents were willing to participate in the
government commitment in health care financing CBHI and to pay premiums ranging from
and risk management related to the cost of ₦400 to ₦1500 for health services that include
illness. For sustainability and growth, surgery and hospitalisation. A significantly high
government and its partners can support the proportion of the respondents showed
growth of CBHIS by ensuring that there is a willingness to make financial contributions for
satisfactory supply of appropriate health other family members. This could go a long way
services, and by subsidizing the start-up and in reducing the catastrophic out-of- pocket health

6
 Azuogu and Eze; AJRIMPS, 4(3): 1-8, 2018; Article no.AJRIMPS.42839
expenditure encountered by most of the
respondents.
Educational status was found to have significant
effects on the respondents’ willingness to
contribute for CBHIS. This variable as predictor
of WTP among respondents is similar to that
found in studies conducted in South eastern [1]
and South western [2] regions of Nigeria.
It is therefore not surprising that this study, which
is also in a low income setting, seems to be in
consonance with the results from those other
studies [1,2,14]. This implies that socio-economic
variables influence respondents’ willingness to
contribute for CBHIS.
5. CONCLUSIONS
Awareness about CBHIs is low among the
artisans. However, there is high level of
willingness to participate and contribute
for the scheme among the respondents amidst
some reservations about government and
private organizers. A well-organized CBHIS
could therefore address the gross inequity in
health care system orchestrated by the high
burden of out of pocket payment for health
care especially among those in the informal
sector.
ETHICAL APPROVAL AND CONSENT
Ethical approval was obtained from Federal
Teaching Hospital, Abakaliki, while written
informed consent was obtained from
individual participants with assurance of
confidentiality.
COMPETING INTERESTS
Authors have declared that no competing
interests exist.
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Peer-review history:
The peer review history for this paper can be accessed here:
http://www.sciencedomain.org/review-history/25837