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Many low and middle-income countries are increasingly cognisant of the need to offer financial protection to its citizens through pre-payment schemes in order to curb high out of pocket expenditure and catastrophic spending on healthcare. However, there is limited rigorous contextual evidence to make decisions regarding optimal design of such schemes. This study assesses the willingness-to-pay (WTP) for the recently introduced state contributory health insurance scheme (SHIS) in Nigeria. The study took place in 6 local government areas in Kaduna state, North-west Nigeria. Data were collected from a household survey using a three-stage cluster sampling approach, with each household having the same probability of being selected. Interviews were conducted with 4000 individuals in 1020 households. Contingent valuation was used to elicit the willing to pay (WTP) for the household using the bidding game technique. The relationship between socioeconomic status and WTP was also examined using logistic regression models. About 82% of the household heads were willing to pay insurance premiums for their households, which came to an average of 513 Naira (1.68 USD) per month per person. The average amount individuals were willing to pay was lower in rural areas (611 Naira) compared to urban areas (463 Naira). These results were influenced by household size, level of education, occupation and household income. In addition, only 65% of the households had the ability to pay the average premium. Socioeconomic factors influence individuals' WTP for contributory health insurance schemes. It is important to create awareness about the benefits of the insurance scheme, especially in rural areas, and in both the formal and informal sectors in Nigeria. WTP information can inform the amount of insurance premiums. However, it is important to consider differences between the WTP and the cost of benefits package to be offered, as the premium amount may need to be subsidized with public financing.

Pay-for-performance (P4P) has recently been introduced in Nigeria to improve quality of health services. Its early results show significant variation between implementation sites. Literature suggests this might be explained by differences in design, context and implementation of the scheme. This study aimed to explore how context and implementation influence P4P in Nigeria. Semi-structured in-depth interviews with 36 health workers explored their views and experiences on how contextual and implementation factors influenced the impact of the P4P scheme. Data were analysed using the framework approach. Four themes captured the views and experiences of participants. Uncertainty of earning the incentive and inadequate infrastructure reduced health worker motivation and performance results; whilst adequate health worker understanding of the scheme and good managerial skills (health facility level) improved motivation and performance. Minimising delays in incentive payments, effective communication and improving the health workers understanding of the P4P scheme are likely to improve the outcomes of pay for performance programmes, independent of their design. La rémunération au rendement (P4P) a récemment été introduite au Nigeria pour améliorer la qualité des services de santé. Ses premiers résultats montrent d’importantes fluctuations entre les divers sites de mise en œuvre. Les documents publiés à ce propos laissent supposer que cela pourrait s’expliquer par des différences au niveau de la conception, du contexte et de la mise en œuvre du programme. La présente étude avait pour objectif d’analyser l’influence du contexte et de la mise en œuvre sur le P4P au Nigeria. Des entretiens semi-structurés approfondis avec 36 agents de santé ont permis d’explorer leurs visions et expériences sur l’influence que les facteurs contextuels et de mise en œuvre ont sur l’impact du programme P4P. Ces données ont été analysées au moyen de l’approche cadre. Les points de vues et expériences des participants transparaissent dans quatre thèmes. L’incertitude de bénéficier de mesures incitatives et l’insuffisance des infrastructures contribuent à réduire la motivation et le rendement des agents de santé; tandis qu’une bonne connaissance du programme associée à de solides compétences managériales des agents de santé (suivant le niveau de la formation sanitaire) renforcent la motivation et le rendement. Le fait de réduire les retards des paiements incitatifs, de rendre la communication plus efficace et de renforcer la connaissance du programme P4P par les agents de santé sont des mesures susceptibles d’améliorer les résultats des programmes de rémunération au rendement, indépendamment de leur conception. El pago por rendimiento (PPR) fue recientemente introducido en Nigeria para mejorar la calidad de los servicios de salud. Sus primeros resultados muestran una variación significativa entre los sitios de implementación. La literatura sugiere que esto podría explicarse por las diferencias en el diseño, el contexto y la implementación del esquema. Este estudio tuvo como objetivo explorar cómo influyen el contexto y la implementación en el PPR en Nigeria. Entrevistas semiestructuradas en profundidad con 36 trabajadores de la salud exploraron sus puntos de vista y experiencias sobre cómo los factores contextuales y de implementación influyeron en el impacto del esquema de PPR. Los datos fueron analizados utilizando el método de marco teórico. Cuatro temas capturaron los puntos de vista y las experiencias de los participantes. La incertidumbre de ganar el incentivo y la inadecuada infraestructura redujo la motivación del trabajador de la salud y los resultados del rendimiento; mientras que la comprensión del trabajador de la salud sobre el esquema y las buenas practicas gerenciales (nivel de las instalaciones de salud) mejoraron la motivación y el rendimiento. Minimizar las demoras en los pagos de incentivos, la comunicación efectiva y mejorar el entendimiento de los trabajadores de la salud del esquema PPR pueden mejorar los resultados de los programas de pago por rendimiento, independientemente de su diseño 绩效工资近期在尼日利亚得到应用, 旨在提高医疗服务质量。 初期结果显示, 不同的区域的实施结果有极大的差别。文献表 明计划在设计、环境和应用中的差别或许能够解释这种差 异。本研究旨在探索环境和实施如何影响尼日利亚的绩效工 资。对36名医疗工作者进行的半结构式深入访谈充分挖掘他 们对环境和应用因素如何影响绩效工资计划效果的观点和经 历。我们通过结构框架方法分析数据。4个主题概括受访者的 观点和经历。获得奖励性工资的不确定性和基础设施的匮乏 降低医疗工作者的积极性和绩效；但是医疗工作者对绩效工 资计划的充分了解和良好的管理技能 （在医疗结构层面） 能 够提高医疗工作者的积极性和表现。降低绩效工资延迟发放 的次数, 有效的沟通和提高医疗工作者对绩效工资计划的理解 很可能在设计层面以外改善绩效工资的效果。

Many factors beyond patient need influence the care that patients receive, including the way physicians are paid, and how services are delivered. In Alberta, outpatient non-invasive cardiac imaging (\"cardiac imaging\") is paid for publicly but performed at private, for-profit (investor/physician owned) facilities. We investigated patient, physician, and geographic factors associated with cardiac imaging in patients at low cardiovascular risk seeing specialist physicians in Alberta, Canada. This was a population-based retrospective cohort study using administrative health data from Alberta, Canada, where nearly all outpatient cardiac imaging is done at privately for-profit community-based facilities. We used administrative health data to identify a cohort of adult (aged ≥18 years) patients at low cardiovascular risk who were assessed by a cardiologist or internal medicine specialist for a new outpatient visit for a cardiac-related reason between April 1, 2011 and December 30, 2019 in Alberta. The primary outcome was cardiac imaging. Explanatory variables included patient and physician characteristics, including payment model (fee for service (FFS) or salary-based), and geography. We used multilevel, multivariable logistic regression models to measure the association between these factors and cardiac imaging. We identified 398,095 patients at low cardiovascular risk, of whom 27.5% received at least one cardiac imaging test. Compared to those seen by FFS cardiologists (and controlling for patient and geographic differences), patients seen by salary-based internal medicine specialists had the lowest odds of receiving cardiac imaging (OR=0.055, P < 0.001, CI 0.036-0.086), followed by those seen by FFS internal medicine specialists (OR=0.010, P < 0.001, CI 0.068-0.14), and salary-based cardiologists (OR=0.27, P < 0.001, CI 0.16-0.45). Findings were robust across multiple sensitivity analyses. Physician payment models and specialty are strongly associated with non-invasive cardiac imaging among patients at low cardiovascular risk.

ObjectivesThis study aimed to assess Nigeria’s preparedness to finance and drive the universal health coverage (UHC) agenda within the context of changing health conditions and resource needs associated with the disease, demographic and funding transitions.Nigeria is undergoing transitions in the healthcare system that include a double burden of infectious and non-communicable diseases, and transition from concessional donor assistance towards domestic financing for health. These transitions will affect Nigeria’s attainment of UHC.Design and settingWe conducted a qualitative study, including semistructured interviews with relevant stakeholders at national and subnational levels in Nigeria. Data from the interviews were analysed using thematic analysis.ParticipantsOur study involved 18 respondents from government ministries, departments, and agencies, development partners, civil society organisations and academia.ResultsCapacity gaps identified by respondents included limited knowledge to implement health insurance schemes at subnational levels, poor information/data management to monitor progress towards UHC and limited communication and interagency collaboration between government agencies and ministries. Furthermore, participants in our study expressed those current policies driving major health reforms like the National Health Act (basic healthcare provision fund) appear adequate to support UHC advancement in theory, but policy implementation is a key challenge due to a lack of policy awareness, low government spending on health and poor evidence generation for information to support decisions.ConclusionOur study found major gaps in knowledge and capacity for UHC advancement in the context of Nigeria’s demographic, epidemiological and financing transitions. These included poor knowledge of demographic transitions, poor capacity for health insurance implementation at subnational levels, low government spending on health, poor policy implementation and poor communication and collaboration among stakeholders. To address these challenges, collaborative efforts are needed to bridge knowledge gaps and increase policy awareness through targeted knowledge products, improved communication and interagency collaboration.

Background Pay for Performance (P4P) has increasingly being adopted in different countries as a provider payment mechanism to improve health system performance. Evaluations of pay for performance (P4P) schemes across several countries show significant variation in effectiveness, which may be explained by differences in design. There is however no reliable framework to structure the reporting of the design or a typology to help analyse and interpret results of P4P schemes. This paper reports the development of a reporting framework and a typology of P4P schemes. Methods P4P design features were identified from literature and then explored using relevant theories from behavioural and economic science. These design features were then combined with the help of multidimensional tables to produce a reporting framework and a typology which was tested using 74 P4P studies. The inter-rater reliability of the typology was assessed using Fleiss’ Kappa. Results A Healthcare Incentive Scheme Reporting Framework (HISReF) was developed consisting of nine design features. This was collapsed into a typology consisting of 4 items/design features. There was good inter-rater reliability on all the four items on the typology (kappa > 0.7). Conclusion The HISReF provides an important first step towards establishing a common language in which intervention designers can clearly specify the content of P4P designs. Our typology may be used to aid evidence synthesis and interpretation of results of P4P schemes.

Background There is widespread and growing interest in designing and implementing social health insurance schemes (SHIS) across many low- and middle-income countries as a means to improve financial protection and achieve universal health coverage. SHIS recently gained traction in Nigeria, but evidence regarding optimal design features of SHIS is sparse and there is lack of a simple and standardised checklist that scheme designers, implementers and researchers could use to assess, guide and inform the design of SHIS. This paper seeks to develop a checklist based on concepts as well as theoretical and empirical evidence that can inform and guide scheme designers and implementers on design options to maximise the effectiveness of the scheme. Methods We conducted a review of literature exploring the relevant concepts for the development of a framework and checklist to identify the key factors or variables required to inform the design of SHIS. The checklist details critical considerations/questions to address and options for design. The developed checklist was then used to examine conditions for readiness and appropriateness of SHIS design in two states in Nigeria (Kaduna and Niger). Results This paper describes the development of a SHIS checklist. The findings also demonstrate that the newly developed checklist, consisting of six design domains, can be used by scheme designers and policy-makers as a simple and effective tool to assess and inform SHIS design features across Nigeria to maximise the chances of the effectiveness of the schemes. Conclusion In conclusion, given that the development of SHIS in the Nigerian states is still in its early stages, applying the SHIS design checklist can serve as a first step to ensuring a feasible and sustainable insurance scheme. The introduction of SHIS, if properly designed and implemented, can be a significant first step towards improving the accessibility, equity and efficiency of healthcare in Nigeria.

Health accounts provide accurate estimates of health expenditure, which are important for effective resource allocation and planning in the health sector. In Nigeria, four rounds of health accounts have been conducted at the national level. However, the national estimates do not necessarily reflect realities at the subnational level and may only provide limited information for decision making at that level. This study highlights the pattern of health spending in Kaduna State from the 2016 Health Accounts, with a view to providing more reliable evidence for decision making in the state.Health accounts expenditure surveys were administered to government, donors, non-governmental organizations (NGOs), private health insurance organisations and employers in the health sector for the reference year 2016. Household health expenditure was derived from a household survey administered across a representative sample of 1024 households selected from six local government areas across the three senatorial districts in the state. We estimated disease expenditure by deploying a health provider survey across a sample of 100 health facilities. Analysis was conducted using Microsoft Excel, Stata and the Health Accounts Production Tool.Findings show that current health expenditure (CHE) accounted for only 7% of the total health expenditure in 2016. Out-of-pocket spending among households was about 81% of CHE, compared with a national average of 71.5% of CHE between 2010 and 2014. The health expenditure findings highlight several policy imperatives for the Kaduna State Health System. Primary among these is the heavy dependence on out-of-pocket financing for health, which has negative implications on vulnerable households. A shift to pooled prepaid mechanisms would reduce the financial burden on the most vulnerable households in Kaduna State. In addition, considering the government’s current contribution to health expenditure, there is a strong need for increased government prioritisation of the Kaduna State health sector.

BackgroundMany factors beyond patient need influence the care that patients receive, including the way physicians are paid, and how services are delivered. In Alberta, outpatient non-invasive cardiac imaging (\"cardiac imaging\") is paid for publicly but performed at private, for-profit (investor/physician owned) facilities. We investigated patient, physician, and geographic factors associated with cardiac imaging in patients at low cardiovascular risk seeing specialist physicians in Alberta, Canada.MethodsThis was a population-based retrospective cohort study using administrative health data from Alberta, Canada, where nearly all outpatient cardiac imaging is done at privately for-profit community-based facilities. We used administrative health data to identify a cohort of adult (aged ≥18 years) patients at low cardiovascular risk who were assessed by a cardiologist or internal medicine specialist for a new outpatient visit for a cardiac-related reason between April 1, 2011 and December 30, 2019 in Alberta. The primary outcome was cardiac imaging. Explanatory variables included patient and physician characteristics, including payment model (fee for service (FFS) or salary-based), and geography. We used multilevel, multivariable logistic regression models to measure the association between these factors and cardiac imaging.ResultsWe identified 398,095 patients at low cardiovascular risk, of whom 27.5% received at least one cardiac imaging test. Compared to those seen by FFS cardiologists (and controlling for patient and geographic differences), patients seen by salary-based internal medicine specialists had the lowest odds of receiving cardiac imaging (OR=0.055, P < 0.001, CI 0.036-0.086), followed by those seen by FFS internal medicine specialists (OR=0.010, P < 0.001, CI 0.068-0.14), and salary-based cardiologists (OR=0.27, P < 0.001, CI 0.16-0.45). Findings were robust across multiple sensitivity analyses.ConclusionsPhysician payment models and specialty are strongly associated with non-invasive cardiac imaging among patients at low cardiovascular risk.

Countries are increasingly implementing pay for performance (P4P) as a way to improve health services. The evidence base is conflicting and difficult to interpret. It is necessary to more systematically explore evaluations of P4P schemes in order to synthesize more useful evidence to inform the use of P4P schemes in health care. This thesis starts with a literature review, which shows that the results of evaluations of P4P schemes are heterogeneous, which may possibly be explained by differences in programme design, context, implementation, and evaluation study design. I sought to find ways to better analyse and make sense of these evaluations using two approaches. A quantitative approach was used to systematically explore the heterogeneity. I developed and tested a theoretical typology to categorise P4P schemes by their design features. This typology considers who receives the incentive, type of incentive, size of incentive, and perceived risk of not earning the incentive. I then used the typology to quantitatively explore the influence of P4P design features and evaluation designs on it effectiveness using meta-regression and multilevel logistic regression analyses. I also undertook a formative evaluation of a pilot P4P scheme in Nigeria (a case study). This used semi-structured in-depth interviews with 36 purposively sampled health workers to explore how contextual and implementation factors (e.g. delay in incentive payment) influenced the impact of the scheme. This research presents three notable and novel contributions to knowledge about P4P in healthcare. First a useful typology was developed, which can be used to help categorize, think about, structure and report P4P schemes in a standardized and theoretically informed way. Second, I show that P4P schemes with design features such as payment to groups, large incentive size (>5% of salary or usual budget), and low perceived risk of not earning the incentive are more likely to be effective compared to schemes characterized by payment to individuals, small incentives, and high perceived risk of not earning the incentive. In addition, I demonstrate that P4P evaluations without adequate controls over-estimate the effectiveness of P4P. Third, I show that contextual factors such as incentive payment delays, poor health worker understanding of the P4P scheme, and poor infrastructure affect the effectiveness of the Nigerian P4P scheme and need to be addressed in its future development.