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Year : 2016  |  Volume : 19  |  Issue : 2  |  Page : 69-73

Impact of national health insurance scheme on blood pressure control in Zaria

1 Department of Medicine, Cardiology Unit, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Department of Paediatrics, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria

Date of Web Publication12-Jul-2016

Correspondence Address:
Albert Imhoagene Oyati
Department of Medicine, Cardiology Unit, Ahmadu Bello University Teaching Hospital, Zaria
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DOI: 10.4103/1118-8561.186037

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Background: National Health Insurance Scheme (NHIS) was commenced in Nigeria in 2001 to ensure wider access to health care services. This study determined the impact of NHIS implementation on blood pressure (BP) control among patients with systemic hypertension, regularly attending the Cardiac Clinic, Ahmadu Bello University Teaching Hospital, Shika, Zaria, Nigeria. Materials and Methods: Patients with systemic hypertension, both NHIS and non-NHIS beneficiaries attending a tertiary health facility in Zaria, Nigeria, were seen in a prospective cross-sectional study. Demographic and clinical characteristics were obtained. Access to treatment and relevant investigations were compared. BP levels were analyzed and compared in both groups at enrollment in the clinic and at the point of this study. Results: Sixty-five percent, (70/107) of the clinic attendees were on the NHIS scheme and were significantly younger than non-NHIS patients (t = 2.03, P = 0.03). Mean body mass index (BMI) was equally high (t = −1.222, P = 0.22) and there was similar access to medications (χ2 = 0.08, P = 0.77). Mean systolic BP (SBP) and diastolic BP (DBP) at enrollment were significantly higher in NHIS patients (t = −3.064, P = 0.003 for mean SBP and t = −4.115, P = 0.0001 for mean DBP), respectively. However, BP control in both groups at the end of the study did not show any significant difference (χ2 = 0.02, P = 0.89). Conclusion: NHIS uptake among these patients is high. There was no difference in BP control among the insured and nonbeneficiaries. A study of a larger number of patients over a longer period is suggested.

Keywords: Blood pressure control, impact, National Health Insurance Scheme

How to cite this article:
Oyati AI, Orogade AA, Azuh PC, Yakubu PD, Shidali VY. Impact of national health insurance scheme on blood pressure control in Zaria. Sahel Med J 2016;19:69-73

How to cite this URL:
Oyati AI, Orogade AA, Azuh PC, Yakubu PD, Shidali VY. Impact of national health insurance scheme on blood pressure control in Zaria. Sahel Med J [serial online] 2016 [cited 2020 Jun 2];19:69-73. Available from: http://www.smjonline.org/text.asp?2016/19/2/69/186037

  Introduction Top

Hypertension is a major public health challenge in all nations,[1] and remains a major risk factor for heart failure, sudden cardiac death, stroke, chronic kidney disease, and blindness.[2] Approximately, 20% of the world population are estimated to be hypertensive (blood pressure [BP] of ≥140/90 mmHg)[1],[2],[3],[4],[5] and an equally worldwide high prevalence of poor BP control.[6],[7],[8],[9],[10],[11] Nonadherence to antihypertensive medications from lack of finance is the single most commonly reported factor suggested for poor BP control.[10],[12] It seems plausible, therefore, that amelioration of this factor through the National Health Insurance Scheme (NHIS) would enhance prospects for optimal BP control.

  Materials and Methods Top

In order to assess the impact of NHIS in achieving BP control among patients with systemic hypertension in Zaria, this cross-sectional study was carried out over a period of 1-year (July 2013 to June 2014), on patients with systemic hypertension, regularly attending the Cardiac Clinic of Ahmadu Bello University Teaching Hospital, Shika, Zaria, Nigeria.

After due ethical clearance was obtained from Ahmadu Bello University Teaching Hospital, Health Research and Ethical Committee, consecutive, consenting hypertensive patients, aged 18 years and above, who were beneficiaries of NHIS, and similarly, consenting, nonbeneficiaries of NHIS were recruited. Only patients, who had been on treatment for 6 months and above, were recruited by convenience sampling using a ratio of 2:1. This is because, with appropriate medication and adherence, BP control is expected within this period. The biodata, clinical information such as duration of hypertension, number of BP lowing drugs, occupation, and social and educational status of patients were obtained and entered into the study proforma. BP was measured manually using standard adult sphygmomanometer placed on the arm of the patient who was at rest, in the sitting position. An average of three consecutive readings was taken.

In addition, the past Cardiac Clinic visit records were diligently examined. The BP at the first visit for both subjects and controls, and the BP at enrollment into the NHIS program (for NHIS beneficiaries) were noted. The average of BP readings recorded during the subsequent follow-up visits was taken. In our Cardiac Clinic, follow-up appointments are given from 3 to 4 months. The average of a minimum of 2 last visits was used in this study. BP was said to have been controlled when a patient maintained BP<140/90 mmHg at the time of the study. Access to investigative modalities: Electrocardiography (ECG), echocardiography, and relevant blood biochemistry were also investigated.

The data for the study were analyzed using SPSS version 20 (IBM SPSS statistics for windows cersion 20.0 Amonk, NY: IBM corporations). Frequencies were obtained for descriptive analysis. However, for comparative analysis, Pearson Chi-square test, independent and paired t-test, and Pearson correlation were performed. A significance level of 5% was used to determine the difference between the two groups (NHIS and non-NHIS beneficiaries).

  Results Top

A total of 107 patients made up of 70 NHIS beneficiaries and 37 non-NHIS beneficiaries were studied. The uptake for NHIS by study subjects was 65% (70/107). There were relatively more female patients than males in both groups (χ2 = 6.31, P = 0.01) as shown in [Table 1]. More NHIS patients had some level of education (χ2 = 20.62, P = 0.000) with a higher proportion of civil servants (χ2 = 24.03, P = 0.000) but similar income levels (χ2 = 1.55, P = 0.21). [Table 2] shows some clinical characteristics of the study population. The patients in the NHIS group were significantly younger, but there was no statistically significant difference between the groups in terms of the body mass index (BMI), which was uniform in the obese range. The systolic blood pressure (SBP) and diastolic blood pressure (DBP) showed statistically significant difference between the two groups being lower in the non-NHIS group. [Table 3] shows access to regular medication responses. There was no statistically significant difference between the two groups (χ2 = 0.08 P = 0.77). At baseline, the subjects were taking an average of 2–3 BP lowering drugs drawn from different classes (diuretics, calcium channel blockers, beta blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers). It was observed that medications were obtained at the same source. The effort to adhere to medication could not, however, be ascertained.
Table 1: Sociodemographic characteristics of study population

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Table 2: Clinical characteristics of study population

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Table 3: Access to care

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With regards to the prescribed laboratory investigations, the NHIS group was better investigated than the non-NHIS group. The number of non-NHIS patients, who were able to perform the prescribed investigations decreased considerably, when the more expensive tests such as lipid profiles, ECG, and echocardiography were involved compared to those on NHIS. Fifty-two (74.3%) of NHIS patients performed lipid profiles as against 19 (51.4%) of non-NHIS. Similarly, while 50 (71.4%) and 41 (57.7%) of NHIS patients performed ECG and echocardiography, respectively, 17 (45.9%) and 14 (37.8%) of non-NHIS patients were able to perform same investigations. Despite this seeming advantage of access to better monitoring, there was no statistically significant difference in the number of those who had their BP in the control range (BP <140/90 mmHg) at the time of enrollment and at the end of the study for both the NHIS and non-NHIS patients (χ2 = 0.02, P = 0.89). Age correlated significantly and positively with BP (r = 0.8, P = 0.03) in both groups.

  Discussion Top

The issue of optimal BP control in hypertensive has continued to engage the minds of health care providers. Several studies have suggested possible factors militating against optimal BP control.[13],[14],[15] One of such often reported factors was an inconsistency in medication due to the prohibitive cost of effective antihypertensive drugs.[10] To stem the tide of unnecessary morbidity and mortality to diseases occasioned by poverty, the NHIS was introduced in Nigeria in 2001 to make health care accessible and affordable to the majority of Nigerians, while reducing the burden of government in financing health care. Based on a repayment system, where both the employer and employee make contributions to enable the employee, access the scheme and when the need arises,[16] reports on such schemes in countries such as Ghana,[17] India,[18] Rwanda,[19] and Tanzania [20] have consistently shown increase in affordability of drugs, access and utilization of health services even among the poor and most vulnerable population. With the introduction of the NHIS in Nigeria, it was expected that more patients would have access to effective antihypertensive drugs which should translate to better BP control, if other factors remain unchanged.

In this study, there has been considerable uptake of the National Health Care Scheme. The demographics of the typical population utilizing this scheme are the working class civil servants who are low-middle income earners. This is a reflection of the modality of operating the scheme where one has to be in an employment. Usually, the government employees are more likely to be registered than those working in private institutions. It is noteworthy, however, that both groups had similar incomes despite the difference in occupation and educational levels. More than half of the non-NHIS were housewives, who are commonly involved in some trading as well. In other countries, the operation of the health insurance schemes favor even the nongovernment employed as well as the unemployed.[16] Health insurance scheme in countries such as Ghana and India have led to increase in the affordability of drugs and health service, especially among the poor and most vulnerable population.[17],[18] Community-based health insurance scheme in Rwanda resulted in the increased utilization of modern health care services and a reduction in catastrophic health-related expenditures. It also showed a higher utilization of health care services among the insured nonpoor than insured poor households with comparable effects in reducing the health-related expenditure shocks.[19]

The regularity in access to medication was similar in both groups even though the non-NHIS patients had no access to free antihypertensive drugs like their NHIS counterparts. Expensive but effective antihypertensive drugs are excluded from the NHIS approved drug list. This, we confirmed from interview with the NHIS patients and examination of the approved NHIS drug list. The General Hospital Pharmacy was the same with the NHIS pharmacy probably to maximize profit for the institution administering the scheme. The only difference was while one group had the drugs free, the other paid for it. The content of what was accessed by both groups was therefore, the same which may explain why there was no statistically significant difference between the two groups when BP control was compared at the end of the study. However, the extra effort to ensure regular medication by the non-NHIS group though they paid for their drugs was probably the result of health information from health care provider about the consequences of irregular medication.[10] In terms of laboratory investigations, the study showed that NHIS patients were better investigated than the non-NHIS. Laboratory investigations are expensive and because of that the non-NHIS patients would rather save their money for drugs instead of laboratory tests. This will, however, have a negative implication for BP management which goes beyond mere reduction of BP, but also involve the monitoring and prevention of end-organ damage through relevant investigative modalities.

The mean difference between the NHIS and non-NHIS patients with regards to SBP and DBP at enrollment was highly significant (P = 0.0001). This observation did not however, translate to a better BP control in the non-NHIS group at the end of the study. Effective management of hypertension or any other chronic disease cannot be achieved by medical care alone. Other variables which are commonly overlooked but play a key role are the effect of social policies, psychological aspects of motivating behaviors in seeking or not seeking care programs to educate, and motivate people to adopt healthy lifestyles. These cannot be resolved by NHIS. In a study, where factory workers had access to medical care under an insurance cover, BP control was still poor because of nonutilization of facilities provided.[21] In another study,[22] where the impact of National Health Insurance (NHI) on treatment for high BP was evaluated, the results provided support for the effectiveness of NHI in increasing utilization of health care and reducing the gap in utilization between the uninsured and insured. The study suggested that this could form the basis for a guideline to formulate health care policies in managing and reducing the adverse effects of high BP.[22] The possible influence of occupation, level of education, and social status taken together on BP control in this study was found to be insignificant, but when age alone was considered, it showed a significant relationship with BP control P = 0.05. BMI in both groups was similar in the obese category. This factor that contributes to hypertensive disease was not addressed adequately nor monitored effectively in the management of these patients.

  Limitations/recommendation Top

This study, though involving relatively few patients as compared to the burden of hypertension in the country has not demonstrated any advantage of being an NHIS beneficiary in relation to BP control. However, NHIS patients had the advantage of better access to relevant investigative modalities for monitoring and prevention of end-organ damage, which is one of the treatment goals in hypertension management. A study of a larger number of patients over a longer period is suggested in the face of apparent negative findings in this study with regards to BP control.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3]


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