The Value of Impact Evaluation
In Africa, limited rigorous impact research is done in the field of community health insurance creating gaps in expertise. Since the introduction of the Health Insurance Fund’s (HIF) program in Kwara State in 2007, an elaborate external evaluation to measure the impacts of providing community health insurance has been put in place in order to improve on this. The first findings of this study, led by the Amsterdam Institute for International Development (AIID), the Amsterdam Institute for Global Health for Global Health and Development (AIGHD) and the University of Ilorin Teaching Hospital (UITH) in Nigeria, have now been published.
As the subject of evaluation, Kwara State, the fourth poorest state of Nigeria, is unique because it has one of the highest per capita out-of-pocket health expenditures in the country representing nearly one-fifth of household spending. For this reason the introduction of community health insurance was designed to be of great value giving the community access to affordable health care and protecting them against high healthcare costs.
The impact evaluation follows a quasi-experimental design methodology based on two population-based household surveys: a baseline survey in 2009 and a follow-up survey in 2011. The baseline and follow-up surveys were implemented on a subset of the population in the area where the program is introduced (treatment area) and in a similar area where the program has yet to be introduced (control area). The evaluation looks at both the effect of the program on the treatment area as a whole compared to the control area and the effect on the individuals who enrolled in the program, i.e. the insured individuals compared to the non-insured in the treatment area. The evaluation, however, does not cover impacts of the program beyond the household such as impacts on providers or on the overall health system.
Since the introduction of the HIF program, approximately 30 percent of the individuals and 45 percent of the households in treatment area have enrolled in the insurance program, amounting to over 71,000 individuals. The results demonstrate that in the area where the health insurance program has been introduced, the use of the health care has on average increased by over 70% in the treatment group after introducing the program. Additionally, a decrease of 40% on average (including the costs of the insurance premium) of out-of-pocket expenditures have been shown.
The findings also suggest that the program has increased awareness about health status among the population in the treatment area. Figures show that both in the treatment area as a whole and among the insured, individuals reflected that their own health has significantly declined. Moreover an increase was seen in the share of individuals that reported having a chronic disease, which may seem alarming. However, increased access to health care can increase awareness about one’s own health status, leading to a decline in positive reflection on it. For the long term, it is expected that increased access to preventive care will improve health status.
In conclusion this impact evaluation uniquely contributed key evidence to the gap in knowledge about interventions that address both the demand and supply side of a health system in the Africa. This knowledge has significantly backed policy makers in making informed decisions on healthcare budgets and policies and it continuously guides HIF and PharmAccess in implementing successful programs in Nigeria and other countries. Due to this success, in the coming years the impact evaluation will be continued to follow the progress and to measure long-term impact.
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