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Title page
Table of contents

Chapter One – Introduction
1.1 Introduction
1.2       Justification
1.3       Problem statement
1.4       Research question
1.5       Aims and objectives
1.6       Scope of the study

Chapter Two – Literature Review
2.1 Health care financing
2.1.1    Revenue collection
2.1.2    Pooled resources
2.1.3    Purchasing

Chapter Three – Methodology
3.1       Background
3.2       Study design
3.3       Study population
3.4       Inclusion/exclusion criteria
3.5       Sampling size determination
3.6       Sampling method
3.7       Data collection instrument
3.4       Data analysis
3.5       Ethical consideration
3.6       Limitations

Chapter Four – Results
4.1       Background characteristics of respondents
4.2       Households sources of finance healthcare services
4.3       Proportion of household income spent on healthcare
4.4       Factors influencing access to health care services by households
4.5       Perception of best methods for payment for treatment

Chapter Five – Discussion, Conclusion and Recommendations
5.1       Discussion
5.2       Conclusion
5.3       Recommendation


Background:One of the main challenges of accessing health care in Nigeria is payment for service at the point of delivery. Out-of-pocket (OOP) payments being the main method of financing health care, has posed a serious constraint in accessing health care. This study assessed the socio-economic status of households in relation to out-of-pocket payment and how these have influenced households‟ access to health care in Keffi, Nasarawa state, North

Central Nigeria. It also provided the necessary information on the options available for health care prepayment other than OOPs.

Method: A cross-sectional household based descriptive study design was used to study out-of-pocket expenditure on health care by households in the settlement. A structured closed-ended interviewer administered questionnaires was administered on eligible 316 household heads or appointed persons selected from listed wards using multistage random sampling technique. Wealth index was developed to assess the socio-economic status of household heads and the equity of OOPs by the use of Principal Component Analysis (PCA). Pearson Chi-square test was used to determine the relationship between OOPs and other categorical variables. Logistic regression was used to examine the multivariate relationship of OPPs.

Results: Of the 316 households 171 sought for treatment within the three months covered by this study. About 66% of households were in the lowest and second quintiles (combined) and only 3.8% is of the highest quintile. Households utilized health care services from traditional healers, patent medicine stores, clinics and hospitals. The educated used the formal health care services more than those with none formal education, however the association was not statistically significant. . Those with lower income accessed clinics and hospitals (63.0%) than the wealthiest (35.0%) who utilized more of patent medicine vendor service but; the difference was also not statistically significant. Ninety eight percent (98.2%) paid directly for health care service while only 1.8% paid for the same service through health insurance, especially, National Health Insurance Scheme (NHIS). The proportion of income spent on health care was 6.22%. The poor spent five times disproportionately higher than the better off and their spending was more catastrophic than the higher income groups.

Conclusion: the main constraint to accessing health care was OOPs which is as a result of none availability of social health insurance or any other form of health care insurance. There is therefore the urgent need to expand the National Health Insurance scheme and introduce the Community Based Social Health Insurance Programme so as to reach those in the non-formal sector.



Out-of-pocket (OOP) expenditure by households was the most important financing agents through which health expenditure sources channel funds to providers for health services in Nigeria and many other low/middle-income countries.1 The world Health organization (WHO) defined Out-of-pocket payment for health care as, „the direct outlay of households, including gratuities and payments in kind, made to health practitioners and supplies of pharmaceuticals, therapeutic appliances and other goods and services whose primary intent is to contribute to the restoration or to the enhancement of the health status of the individual or population groups. It includes household payments to public services, non-profit institutions and nongovernmental organizations. It also include none reimbursable cost sharing deductions, co-payments and fee-for-service, but excludes payments by companies that deliver medical and paramedical benefits whether required by law or not, to the employee and also excludes payment for overseas treatmen'.2 OOP expenditure on health has been observed through the years to be disproportionately higher among most developing countries than the developed ones. For example,

Nigerian‟s private health expenditure as percentage of total expenditure on health in 2008 stood at 74.7%, out of this OPPs expenditure constituted 95.9%3 while the total government expenditure during this same period stood only at 25.3%.3 This suggests that government and privately organized institutions are not making enough investment in the health of the people which is supposed to be a national priority and that much of the burden of health care is bored by individuals and households.....

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