Feasibility of Establishing Community-Based Health Insurance (CBHI) Scheme: A Comparative Analysis of Existence of CBHI Preconditions, and Capacity and Willingness to Pay in 5 Locations in Adamawa, Nigeria

Download Article

DOI: 10.21522/TIJAR.2014.13.01.Art016

Authors : Innocent Chinedu Udemezue, Amitabye Luximon-Ramma, Ebenezer Obi Daniel

Abstract:

Health systems financing in Adamawa is heavily dependent on out-of-pocket (OOP) expenditure. These expenditures predispose poor households to financial hardship, and blocks progress towards universal health coverage. Hence, adopting alternative health financing mechanisms is critical to expanding informal sector and vulnerable population’ access and utilization of quality healthcare services. This study evaluated the feasibility of establishing community-based health insurance (CBHI) scheme based on findings from assessment of six preconditions for setting up CBHIs, and respondents’ capacity and willingness to pay for CBHI in five locations in Adamawa. The mixed method study adopted used the sequential explanatory design classification method. The method used to elicit willingness to pay (WTP) is an adaptation of the contingent valuation method and specifically, the bidding game method using the Dutch system sequence. Findings showed respondents willing to pay a fee to join as individuals and enrol household members comprised 88.5% and 85.3% respectively. The mean individual out-of-pocket (OOP) expense was N3,820 in Damare, N5,617 in Dumne, N4,819 in Imburu, N4,732 in Mbilla, and N7,863 in Sabon Pegi. These amounts were at least twice the highest willingness to pay premium option of 1,500 offered for a standard CBHI service package. Expressing mean personal income left after spending on basic necessities as a percentage of mean personal monthly income in each district resulted in values which ranged from 9.94% in Imburu, to 56.2% in Damare. Findings from this study has demonstrated the existence of the six preconditions for setting up CBHI scheme, and ultimately, the feasibility for establishing CBHI scheme in Adamawa. The study also showed that the willingness and capacity to pay was substantial enough to promote the successful roll out of a viable community driven CBHI scheme.

References:

[1].   Bloom, D. E., Khoury, A., and Subbaraman, R., 2018, The promise and peril of universal health care. Science (New York, N.Y.), 361(6404), eaat9644. https://doi.org/10.1126/science.aat9644

[2].   Woldemichael, A., Gurara, D., and Shimeles, A. A., 2019, The impact of community-based health insurance schemes on out-of-pocket healthcare spending: evidence from Rwanda. IMF Working Papers, 2019(038).

[3].   Banerjee, A., Hanna, R., Olken, B. A., and Sverdlin Lisker, D., 2024, Social Protection in the Developing World. Journal of Economic Literature, 62(4), 1349–1421.

[4].   Monitoring, Evaluation, Accountability, and Learning (MEAL) Plan 2024 to 2028: Adamawa State Social Protection Policy. October, 2023. https://www.google.com/search?q=adamawa+social+p

[5].   Umaru, W., Hassan, M., Veino, B., and Bawuro, M., 2024, Assessment of Prevalence Rate of Maternal Mortality in Adamawa State, Nigeria. ResearchGate. https://doi.org/10.47001/IRJIET/2024.804010

[6].   Okafor, M., 2025, Nigeria maternal mortality: The world’s worst country to give birth. June 2, https://www.bbc.com/news/articles/c5yk8ek86kdo

[7].   NDHS, 2023/24. Federal Ministry of Health and Social Welfare (FMoHSW), National Population Commission (NPC), and ICF (2024).

[8].   Nwanze, L., Siuliman, A., and Ibrahim, N., 2023, Factors associated with infant mortality in Nigeria: a scoping review. PloS One, 18(11).

[9].   Ijeoma, U. N., Unaogu, N. N., Onyeka, T. I., Nwatu, C. B., Onyekonwu, C. L., Onwuekwe, I. O., Ugwumba, F., Nwutobo, R. C., and Nwachukwu, C. V., 2019, Health-related quality of life in people with chronic diseases managed in a low-resource setting – a study from South East Nigeria. Nigerian Journal of Clinical Practice, 22(9), 1180.

[10].  Usman, M., 2025, October, 25, Nigeria targets 44m citizens under health insurance coverage by 2030 — Pate. The ICIR – Latest News, Politics, Governance, Elections, Investigation, Factcheck, Covid-19. October 25, 2025. Accessed October 30, 2025. https://www.icirnigeria.org/nigeria-targets-44m-citizens-under-health-insurance-coverage-by-2030-pate/

[11].  Ogbuoji, O., and Yamey, G., 2019, How many child deaths can be averted in Nigeria? Assessing state-level prospects of achieving 2030 sustainable development goals for neonatal and under-five mortality. Gates Open Research, 3, 1460.

[12].  Nigeria Health Watch, 2025, January 29, Assessing the impact of the USAID funding freeze on Nigeria’s health sector. Nigeria Health Watch. https://articles.nigeriahealthwatch.com/assessing-the-

[13].  National Health Insurance Authority (NHIA), 2025, December, Financial access to healthcare for all Nigerians: status of health insurance enrolment coverage by states as of Q3 2025. https://www.nhia.gov.ng/

[14].  Pillah, P., 2025, Evaluation of the performance and challenges of the national health insurance scheme (NHIS) in Nigeria. Retrieved November 22, 2025, from https://www.researchgate.net/publication/369230792_

[15].  Namyalo, P. K., Mutatina, B., Byakika, S., Walimbwa, A., Kato, R., and Basaza, R. K., 2023, The feasibility analysis of integrating community-based health insurance schemes into the national health insurance scheme in Uganda. PLOS ONE, 18(4), e0284246.

[16].  Chemouni, B., 2018, The political path to universal health coverage: Power, ideas and community-based health insurance in Rwanda. World Development, 106, 87–98. https://doi.org/10.1016/j.worlddev.2018.01.023

[17].  Getahun, G. K., Kinfe, K., & Minwuyelet, Z., 2023, The role of community-based health insurance on healthcare-seeking behaviour of households in Addis Ababa, Ethiopia. Preventive Medicine Reports, 34, 102234.

[18].  Kakama, A. A., Namyalo, P. K., and Basaza, R. K., 2020, Feasibility and desirability of scaling up Community-based Health Insurance (CBHI) in rural communities in Uganda: Lessons from Kisiizi Hospital CBHI scheme. BMC Health Services Research, 20(1), 662.

[19].  World Health Organisation (WHO), 2025, March, Community based health insurance, Retrieved January 1, 2026, from https://www.who.int/news-room/fact-sheets/detail/community-based-health-insurance-CBHI

[20].  Health Policy Project. 2011, Community-based health insurance brief: Nigeria. chrome-extension://efaidhttps://www.healthpolicyproject.com/pubs/97_communitybasedhealthinsurance.pdf

[21].  International Labour Organization (ILO), 2005, Health micro-insurance schemes: feasibility study guide Volume 1: https://www.ilo.org/wcmsp5/groups/public/@asia/@ro-bangkok/@ilo-

[22].  Bolarinwa, O. A., Ameh, S., Ochimana, C., Oluwasanu, A. O., Okello, S., Mohamed, S. F., Muhihi, A., & Danaei, G., 2021, Willingness and ability to pay for healthcare insurance: A cross-sectional study of Seven Communities in East and West Africa (SevenCEWA). PLOS Global Public Health, 1(11), e0000057.

[23].  Mbagwu, G., 2018, Factors influencing membership of farmers in cooperative societies in Abia state, Nigeria. Scientific Papers Series Management, Economic Engineering in Agriculture and Rural Development, 18(1), 2018 PRINT ISSN 2284-7995, E-ISSN 2285-3952.

[24].  Danjuma, I. G., 2020, Appraising the influence of socio-economic characteristic of members on their level participation in cooperative society in Adamawa state, Nigeria. International Journal of Scientific and Research Publications, 10(4), April 2020. ISSN 2250-3153.

[25].  Nosratnejad, S., Rashidian, A., Dror, D. M., 2016, Systematic review of willingness to pay for health insurance in low- and middle-income countries. PLoS One. 2016;11(6):1–14.

[26].  Babatunde, O., and Akande, T., 2012, Willingness to pay for community health insurance and its determinants among household heads in rural communities in north-central Nigeria. IrsshCom. 2012; 2 (2): 133–42.

[27].  Kibret, G. D., Leshargie, C. T., Wagnew, F., Alebel, A., 2019, Willingness to join community-based health insurance and its determinants in the East Gojjam Zone, Northwest Ethiopia. BMC Res Notes [Internet]. 2019;12(1):1–5.

[28].  Shepperd, D. S., Benjamin, E. R., 1988, User fees and health financing in developing countries: mobilising financial resources for health. In: DE BeU and MR Reich (eds) Health, Nutrition and Economic Crises: Approaches to Policy in the Third World. Mass., USA: Auburn House, 1988.

[29].  Ujah, I. A. O., Awa, M. J., Meshak, D. J., Garba, R. M., Ajibola, S., Onyekwelu, J., & Lamu, N. M., 2024, Assessment of patients’ satisfaction with healthcare services provided under the Nigeria National Health Insurance Authority. Nigerian Medical Journal: Journal of the Nigeria Medical Association, 65(5), 621.

[30].  Effiong, F., Dine, R. D., Hassan, I., Olawuyi, D., Isong, I., & Adewole, A., 2025, Coverage and predictors of enrollment in the state-supported health insurance schemes in Nigeria: A quantitative multi-site study. BMC Public Health, 25. https://doi.org/10.1186/s12889-025-23329-4

[31].  De Allegri, M., Sanon, M., Sauerborn, R., "To enrol or not to enrol? A qualitative investigation of demand for health insurance in rural West Africa. Soc Sci Med. 2006;62(6):1520–7.

[32].  Abebe, Y., & Belayneh, F., 2023, Determinants of willingness to pay for community-based health insurance scheme among households in rural community of southern Ethiopia. BMC Health Services Research, 23(1), 1365.

[33].  Magge, H., Cabral, H. J., Kazis, L. E., Sommers, B. D., 2013, Prevalence and predictors of underinsurance among low-income adults. Journal of General Internal Medicine. 2013;28(9):1136–1142.

[34].  Bamidele, J. O., Adebimpe, W. O. 2012, Awareness, attitude and willingness of artisans in Osun State, Southwestern Nigeria, to participate in community-based health insurance. J Community Med Prim Health Care. 24:1–10.

[35].  Anderson, I. E., Adeniji, F. O., 2019, Willingness to pay for social health insurance by the self-employed in Port Harcourt, Rivers State: A Contingent Valuation Approach. Asian J Adv Res Rep. 7:1–15.

[36].  Garedew, M. G., Sinkie, S. O., Handalo, D. M., Salgedo, W. B., Yitebarek Kehali, K., Kebene, F. G., Waldemarium, T. D., & Mengesha, M. A., 2020, Willingness to join and pay for community-based health insurance among rural households of selected districts of Jimma Zone, Southwest Ethiopia.

[37].  CHECOD, 2017, Highlights of feasibility study for community-based health insurance scheme | Center For Health Economics Development. Retrieved July 13, 2025, from https://blog.checod.org/highlights

[38].  Sampieri, H., and Collado, F., 2014, Metodología de la Investigación. McGraw-Hill Interamericana Editores, S.A. DE C.V, Ciudad de México.

[39].  Giannouchos, T. V., Ukert, B., Vozikis, A., Steletou, E., and Souliotis, K., 2021, Informal out-of-pocket payment experience and individuals’ willingness to pay for healthcare services in Greece. Health Policy, 125(6), 693–700.

[40].  Adebayo, E. F., Uthman, O. A., Wiysonge, C. S., Stern, E. A., Lamont, K. T., & Ataguba, J. E., 2015, A systematic review of factors that affect uptake of community-based health insurance in low-income and middle-income countries. BMC Health Services Research, 15(1), 543.

[41].  Russell, S., 1996, Ability to pay for health care: concepts and evidence. Health Policy and Planning, 11(3), 219–237.

[42].  Magaria, B. R., Shauri, N. E., & Masanyiwa, Z. S., 2023, Household’s ability to afford health insurance packages in Tanzania. Open Journal of Social Sciences, 11(4), 59–73. https://doi.org/10.4236/jss.2023.114005

[43].  Onwujekwe, O., Uzochukwu, B., and Kirigia, J., 2011, Basis for effective community-based health insurance schemes: Investigating inequities in catastrophic out-of-pocket health expenditures, affordability and altruism. African Journal of Health Economics, 1(1), Article 1.

[44].  Anbari, Z., Mohammad, N., Mohammad, A., and Ebrazeh, A., 2014, Health Expenditure and Catastrophic Costs for Inpatient- and Outpatient Care in Iran—PMC.

[45].  Banerjee, A., Duflo, E., Hornbeck, R., 2018, How much do existing borrowers value microfinance? evidence from an experiment on bundling microcredit and insurance. Economica. Oct;85(340):671-700.

[46].  Adebayo, A. A, and Tukur, A. L., 1999, Adamawa State in maps publication Department of Geography, Federal University of technology Yola, in Co-operate with paraclete publications. A division of paraclete and sons Nigeria. https://www.researchgate.net/figure/Map-of-Adamawa-State-indicating-the-study-area-Source-Adebayo-1999_fig1_328593330