Out-of-pocket expenditures, equity in maternal health care utilisation and health outcomes in Nigeria
Salewa, Adetsav Asen Omonike
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Health is a highly valued asset and a prerequisite for productive activities. This is because poor health limits the production capacities of the affected person and their ability to enjoy the good things of life. To achieve desirable and sustainable health outcomes, health care expenditure must focus on promoting health service delivery and improving health service utilisation. Despite Nigeria's commitment to international and regional agreements, her health sector has been continually underfunded by successive governments. Public health expenditure as a percentage of government expenditure stood at 3.2 per cent in 2001, increased to 9.4 per cent in 2007 but fell consistently to 5.2 per cent in 2013. This is low compared to the Abuja Declaration target of 15 per cent. Also, a greater proportion of the country's total health expenditures are borne by households through out-of-pocket expenditures. Out-of-pocket expenditure as a percentage of total health expenditure was 67.9 per cent in 1995 but dropped to 61.7 per cent in 2000 after which it increased to 69.4 per cent in 2013. This fell short of the Millennium Development Goals target of 30-40 per cent. It is also considerably below the 2015 Sustainable Development Goal target of zero per cent. The health sector in Nigeria also suffers low prevalence of risk-pooling arrangements and inequity in maternal health care utilisation. This makes Nigeria to be one of the countries with the highest rate of infant and maternal mortality in the world. India and Nigeria together account for more than a third of all under-five deaths and second highest maternal mortality rate globally at 14 per cent after China's 20 per cent. This study aimed at examining out-of-pocket expenditure, equity in maternal health care utilisation and health outcomes in Nigeria. The study adopted a cross-sectional research design. Data was obtained from the 2013 General Household Survey as well as 2008 and 2013 Demographic and Health Surveys. Two-part, Logistic Regression and Recursive Bivariate Probit models were estimated. The study found that the major determinants of out-of-pocket expenditure in Nigeria were: region of residence, sex, age, insurance coverage, household size, reported illness, admission in hospitals and occupation. In addition, the differences in equity gaps in skilled birth attendant and delivery in health facility for rural-urban and poor-rich gaps, widened but antenatal visits improved greatly with the richest wealth quintile being favoured. However, along regional divides, the differences in equity gaps in delivery in health facility widened while equity gaps for skilled birth attendant and antenatal visits improved with the South West zone being favoured. Lastly, increased utilisation of skilled birth attendant improved health outcomes significantly in Nigeria. This study, therefore, recommended that: greater consideration should be given to increasing the level of government budget for health, efforts on sensitising citizens on good health seeking behaviours should be intensified, Primary Health Care should be strengthened by government, health insurance coverage should be scaled up and policy makers at all levels should put in place effective and efficient monitoring mechanism to ensure accountability and enforcement of best practices.