JAMA Network

Effect of Health Insurance and Facility Quality Improvement on Blood Pressure in Adults With Hypertension in Nigeria

Editor's Note: This paper was originally published on the JAMA network website.

Hypertension is the leading risk factor for death in sub- Saharan Africa. The age-standardized prevalence of hypertension in the adult population (aged ≥25 years) in sub-Saharan Africa ranged from 38% to 56% in 2008 compared with 30% in the United States and 26%to 44% in Western Europe. In Nigeria, the age-standardized prevalence of hypertension was 49% in the adult population in 2008. As a consequence, the burden of cardiovascular disease (CVD) and stroke in particular is rising in sub-Saharan Africa. Disability adjusted life-years resulting from stroke range from 1163 to 2453 in most sub-Saharan African countries, including Nigeria, compared with 50 and 484 in Western Europe and the United States, respectively. Reduction of blood pressure greatly reduces mortality due to CVD. However, the level of antihypertensive treatment coverage in sub-Saharan Africa is low. Hypertension has been identified as an important health problem in rural Kwara State, Nigeria, with a prevalence of 21% in the adult population (aged ≥18 years),with low levels of awareness (8%), antihypertensive treatment coverage (5%), and blood pressure control (3%) among those with hypertension.

Almost 50% of total health care expenditures in low- and middle-income countries are paid out of pocket by the patients. As a result, the ability to pay for health care has become a critical issue in these countries. Interventions to increase the ability to pay for health care, such as health insurance programs, provide financial protection, there by increasing use of health care resources. Health insurance programs may be particularly useful for patients with chronic conditions, such as hypertension, because long-term treatment is unaffordable for many patients. However, studies that evaluate the relation between interventions to increase the ability to pay for health care and health status in low- and middle-income countries are scarce and have provided conflicting results, possibly because most of these studies were retrospective and used cross-sectional data or because of the poor quality of the health care provided.

Community-based health insurance (CBHI) programs (also called health insurance for the informal sector or micro–health insurance) are health insurance programs that share the following 3 characteristics: not-for-profit prepayment plans, community empowerment, and voluntary enrollment. The Health Insurance Fund is an international development organization committed to promoting access to quality health care for low- and middle-income groups in several African countries through innovative financing mechanisms and quality improvement. The first 2 Health Insurance Fund programs were started in 2007 in Lagos and in Kwara State, Nigeria, under the name of Hygeia Community Health Care. The insurance package provides coverage for primary and limited secondary health care, including antihypertensive treatment. In addition, the program improves the quality of care in the health care facilities participating in the program by upgrading of facilities, training of staff in guideline-based care, and hospital management support. Further details of the Hygeia Community Health Care program are described in the Supplement (eMethods). In this study, we evaluated the effect of a CBHI program on blood pressure in a hypertensive population in rural Nigeria.