Universal Healthcare and Access to the Lower-Income Population: An Exploration of Capitation in Lagos, Nigeria

By E. Charles Ezuma-Ngwu

This book presents a research-based exploration of Universal Healthcare and the benefits of healthcare providers’ capitation payment method in many developing economies. The author begins the research study by describing the history of healthcare in Nigeria and exposes a country’s healthcare problem that must be addressed to ensure healthcare access to the low-income population. The book leads the reader through perspectives on the major world’s healthcare payment systems, which include (a) diagnosis-related group (DRG); (b) pay-for-performance (P4P); (c) global budgeting payment systems; (d) fee-for-service (FFS) payment system; and (e) a provider-based capitation payment (PBCP) system. The author provides further review on the advent of geospatial mapping and healthcare, PBCP in lower- and middle-income countries (LMIC), and the current conditions at private outpatient medical centers (POMC) in Lagos, Nigeria. The study’s qualitative approach called for an inductive and deductive data analysis, with a bottom-up approach to building patterns and a comprehensive set of themes. To visualize the results of the predominant fee for Service  (FFS) healthcare payment method in many developing economies and its associated catastrophic health outcomes, the study presents geospatial maps of this urban city and the socio-economic issues it produces. To deliver a successful capitation payment model for healthcare providers in Lagos, Nigeria, the author incorporated a framework model that included incentives and sanctions through an indirect principal-agent relationship, where the principal (enrollees) holds the government accountable for the healthcare provider’s actions (Baez-Camargo & Jacobs 2013). The study in this book concludes by delivering a visual template for transitioning from FFS based healthcare payment system to a more productive environment for both healthcare providers and patients to deliver and receive quality health outcomes and reach the lower-income population.

• Language: English
• Publisher: Archway Publishing
• Release date: Jul 30, 2021
• ISBN: 9781665709309

E. Charles Ezuma-Ngwu

Dr. E. Charles Ezuma-Ngwu is an award-winning top-performing Financial and Budget Analysis and Strategic Performance leader with a proven 20+year track record of dramatically increasing the integrity and utility of financial data used in the healthcare business decision process. He obtained his Ph.D. in Healthcare Administration from the Northcentral University, an MBA from the University of Pittsburg, Katz Graduate School of Business, and B.S in Accounting and Economics from the University of Massachusetts, Lowell, MA. He has extensive experience in research, planning, forecasting, and variance analysis to reduce operational risks in the Healthcare Industry. Dr. Ezuma-Ngwu is happily married and blessed with four children.

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Copyright © 2021 E. Charles Ezuma-Ngwu.

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ISBN: 978-1-6657-0929-3 (sc)

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ISBN: 978-1-6657-0930-9 (e)

Library of Congress Control Number: 2021913850

Archway Publishing rev. date: 07/28/2021

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ABSTRACT

IN THE 2019 Nigerian healthcare landscape, there remains a continuing gap between the Nigerian government’s efforts to provide affordable healthcare access to all its citizens and the ability of the National Health Insurance Scheme to reach the lower-income population. The purpose of this qualitative case study was to explore how a provider-based capitation payment (PBCP) system may provide affordable healthcare access for the disease control needs of low-income population clusters in Lagos, Nigeria, with a focus on disease prevention. The principal-agent theory was selected to frame this study and explore projections for the implementation of the PBCP model. ArcGIS software application, datasets for Lagos, income data from the Lagos State Ministry of Economic Planning and Budget (2017), and an existing USAID-sponsored census study were used to produce a picture of private outpatient medical center (POMC) locations within the higher- and lower-income communities of Lagos. Geospatial maps were developed using the Clemmer model. Results presented in this study provide a geospatial view of provider-based clinic locations in Lagos, Nigeria. The triangulation of data obtained from a 2015 USAID-sponsored census study, Lagos Bureau of Statistics, and Lagos Health Management Agency produced themes from several maps that showed healthcare provider-based clinics with one to five doctors layered with population demographics, income demographics, reported diseases distribution, proportional size information, and distance radius information on clinics. The study shows from a geospatial level a general clustering of clinics in metropolitan areas of disease-reporting paucity and scarcity of both clinics and Health Management Organizations (HMOs) in the outskirts of the urban areas and other lower-income locations. Further research also needs to be conducted to explore the most efficient capitation system to ensure quality care for Nigeria’s lower-income citizens.

ACKNOWLEDGMENTS

THIS DISSERTATION IS dedicated to my amazing and inspiring family. I owe my successful completion of this doctoral research to my wife for her unconditional love and encouragement. In the days leading to my dissertation defense, we had traveled to my ancestral village in Nigeria, where mobile and data networks were very spotty. My dear wife helped me locate the mobile network tower near a church in the village. She drove me to the location for the Zoom presentation and held the portable mobile Wi-Fi device pointed to the best wireless reception for the duration of the presentation. I am eternally grateful for her efforts and support.

I also want to thank my children for their support and empathy for the long hours and always looking for a way to make the journey less painful. I am so grateful to my mother for her constant encouragement and emotional support. I also want to thank my brothers, Nnanna, Gozie, and especially Chidi, who was also on his Ph.D. journey and provided excellent support. I am happy to say that we both earned our doctoral research degrees the same year in 2019. To my exceptional only sister, Ugonne, you have been my cheerleader throughout my journey. Thank you for your over-the-top encouragement.

Finally, I want to thank Dr. Sharon Kimmel for being the absolute best dissertation chair any research student would be assigned. Dr. Kimmel was excellent in her encouragement, belief in me as an accomplished individual, prompt reviews, and feedbacks. I really appreciate her exemplary support.

The journey was challenging, richly inspiring, and rewarding, and I have gained so much knowledge in my area of specialization. I believe the content of this research will provide the reader with additional insight into the healthcare conditions in Lagos, Nigeria, and many similar urban cities in Africa and other developing economies.

FORWARD

THE SCOURGE OF diseases and mortality in many underserved populations in the world remains a daunting task to overcome. We must continue to innovate in ways that propel needed healthcare services to these populations. Productivity in these countries depends on access to quality healthcare.

The author has laid out a template for delivering healthcare to defined populations in underserved communities. The research discussed in this book introduces a geospatial method for delivering healthcare to lower-income populations. Throughout the research process, the author relied on my advice and guidance.

As a Professor of Global Health and Community/Preventative health, I have extensive experience with strategic, policy, and operational issues in public health. As a former senior health advisor in US and Africa health systems as well as a consultant to several multilateral and continental organizations, I find insights articulated in this book very engaging and encouraging. As the author of several books and peer-reviewed articles on public health, the broad topic of this book, healthcare financing in low-income populations, remains extremely important to policymakers, researchers, advocacy groups, and target populations. In my earlier professional years as a clinician in severely resource-challenged environments amidst huge health disparities, this book is a firm reminder that timely access to quality healthcare services requires careful review and creative resolution of healthcare financing challenges.

The world today is a global village. The global economy is intertwined with global health status, as vividly demonstrated with the COVID-19 pandemic. Any outbreak of a new disease in one corner of the world can spread worldwide within a few hours, days, and weeks. Collaboration among countries through the United Nations, World Health Organization, the World Bank, and other organizations look at proactive ways to ensure proper surveillance of disease outbreaks and intervention. Global philanthropies and private-funded financing mechanisms are increasingly active in coordinated, global efforts to tackle new, emerging health challenges such as HIV/AIDS and Ebola. Out-of-the-box healthcare financing mechanisms continue to dominate global health systems and practices in the last 30 years as public and private sector leaders grapple with gargantuan human resources, logistics, and infrastructure challenges in global health.

This book explores a universal healthcare approach to the distribution of private healthcare centers, especially in low-income areas, and incentives to attract these private facilities to serve target populations in poorer communities with demonstrable healthcare needs.

As a friend and colleague for over twenty years, E. Charles (or Ezuma, as I like to call him) has been fascinated with healthcare issues in developing economies. Before starting his research, he sought my advice for developing a roadmap that led to the completion of the doctoral research that is the foundation of this book. This book looks at the existing landscape of private healthcare clinics in the most populous city in Africa, Lagos, Nigeria.

Utilizing geocoded census data for Lagos from the United States Agency for International Development (USAID) for all private outpatient clinics and reported notable diseases and demographic data from the Lagos State Government, Nigeria Bureau of Statistics, the author provides a compelling picture of healthcare disparities and unmet needs. With the geocoded clinic locations and other data inputs incorporated into this study, a theme begins to emerge regarding gaps in delivering healthcare to impoverished locations in the city. The author provides an evidence-based solution to expanding access to these previously unreachable communities with quality healthcare.

This book expands on the growing body of knowledge regarding the use of geospatial methodology to study and make recommendations on viable health policy and healthcare financing options on providing quality, timely, affordable health services to impoverished populations. Governments around the world can use existing data to design and implement credible funding mechanisms to expand access to health services among target populations. Additionally, the book provides a roadmap on how governments and policymakers can allocate scarce healthcare resources to indigent individuals, families, and communities participating in public-funded, population-based capitation payment health insurance systems.

A firmly established scenario that emerges in this book is the possibility that public-private healthcare partnerships anchored on valid population-based data can lead to viable, creative funding mechanisms and templates to address health disparities. Furthermore, this book details the creative use of secondary data analyses from existing public records to make far-reaching policy and operational recommendations on strengthening existing healthcare delivery mechanisms in defined populations.

Dr. Chinua Akukwe

Washington, DC

CONTENTS

Abstract

Acknowledgments

Forward

Chapter 1

Plan for PBCP

Statement of the Problem

Purpose of the Study

Theoretical Framework

Nature of the Study

Research Questions

Significance of the Study

Definitions of Key Terms

Summary

Chapter 2: Literature Review

Theoretical Framework

Perspectives on the Major World’s Healthcare Payment Systems

Diagnosis-Related Grouping (DRG)

Pay-for-Performance Payment System (P4P)

Global Budgeting Payment System

Fee-for-Service (FFS) Payment System

Provider-Based Capitation Payment (PBCP) Systems

The Advent of Geospatial Mapping and Healthcare

PBCP in LMIC

Current Conditions of POMCs in Lagos

Managed Care Organizations and POMCs

Documentation

Summary

Chapter 3: Research Method

Research Methodology and Design

Population and Sample

Materials/Instrumentation

Study Procedures

Data Collection and Analysis

GIS Mapping

Assumptions

Limitations

Delimitations

Ethical Assurances

Summary

Chapter 4: Findings

Trustworthiness of the Data

Results

Sparsity of Clinics in the Outskirts

Evaluation of the Findings

Summary

Chapter 5 : Implications, Recommendations, and Conclusions

Implications

Recommendations for Practice

Recommendations for Future Research

Conclusions

References

LIST OF TABLES

Table 1.1. E. Charles Ezuma-Ngwu, 2019 Dataset Variables

Table 3.1 Average number of patients per day

Table 3.2 E. Charles Ezuma-Ngwu, 2019 Distribution of healthcare facilities in Lagos, Nigeria, in the 2014 Census count

Table 3.3 E. Charles Ezuma-Ngwu, 2019 Sources of data for higher- and lower-income communities in Lagos, Nigeria

Table 4.1 E. Charles Ezuma-Ngwu, 2019 Sorted from Lowest to highest income LGAs in Lagos, Nigeria

Table 4.2 Total reported disease cases by LGA in Lagos, Nigeria

Table 4.3 E. Charles Ezuma-Ngwu, 2019 Average persons per clinic based on population size and number of clinics per LGA

LIST OF FIGURES

Figure 1.1 Current Design of Capitation Payment Model in Nigeria

Figure 1.2. E. Charles Ezuma-Ngwu, 2019 Researcher’s plan for providing direct PBCPs to POMCs in Nigeria

Figure 2.1 The Brinkerhoff and Bossert Governance Principal-Agent Framework

Figure 2.2 2015 Map of Lagos State with all twenty LGAs.

Figure 2.3 Map of Lagos land expansion history from 1900 to 2006

Figure 4.1 Lagos State, Nigeria, showing all LGAs, 2015

Figure 4.2 Reported cases of AIDS in Lagos, Nigeria

Figure 4.3 2015 Reported Cases of Malaria in Lagos, Nigeria

Figure 4.4 Cut-Out Map of Area with the appearance of a concentration of Clinics and Reported Diseases

Figure 4.5 Map with Distribution of Reported Cases of Tuberculosis in Lagos, Nigeria

Figure 4.6 2015 Outlay Maps of Various Categories of Private Outpatient Medical Centers (POMC) in Lagos, Nigeria

Figure 4.7 Population Distribution Map and Clinic Locations in Lagos, Nigeria

Figure 4.8 2015 Revenue Map Showing Areas of Lower and Upper Income based on Revenue Reciepts and a proportional distribution of Clinics with 1-5 Doctors in Lagos, Nigeria

Figure 4.9 Distribution of HMO Offices in Lagos, Nigeria

Figure 4.10 Radial distance Map of Clinics Locations in some Lower Income LGAs in Lagos Nigeria excluding clinics in surrounding LGAs

Figure 4.11 Distance Map of the Sparsely Distributed Clinics in Epe LGA

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CHAPTER 1

IMPROVING ACCESS TO healthcare for the poor and middle class is a significant concern of politicians around the world, including many West African countries, such as Nigeria (Ibiwoye and Adeleke 2008). Nigeria’s national healthcare system, the National Health Insurance Scheme (NHIS), has often been described as being low quality and poorly run (Chukwu, Garg, and Eze 2016; PWC 2016). The NHIS was initially conceived and implemented to encourage competition among participating providers