title: The effect of health insurance and health facility-upgrades on hospital deliveries in rural Nigeria: a controlled interrupted time-series study.
abstract: BACKGROUND
  Access to quality obstetric care is considered essential to reducing maternal and new-born mortality. We evaluated the effect of the introduction of a multifaceted voluntary health insurance programme on hospital deliveries in rural Nigeria.
  
  
  METHODS
  We used an interrupted time-series design, including a control group. The intervention consisted of providing voluntary health insurance covering primary and secondary healthcare, including antenatal and obstetric care, combined with improving the quality of healthcare facilities. We compared changes in hospital deliveries from 1 May 2005 to 30 April 2013 between the programme area and control area in a difference-in-differences analysis with multiple time periods, adjusting for observed confounders. Data were collected through household surveys. Eligible households ( n = 1500) were selected from a stratified probability sample of enumeration areas. All deliveries during the 4-year baseline period ( n = 460) and 4-year follow-up period ( n = 380) were included.
  
  
  RESULTS
  Insurance coverage increased from 0% before the insurance was introduced to 70.2% in April 2013 in the programme area. In the control area insurance coverage remained 0% between May 2005 and April 2013. Although hospital deliveries followed a common stable trend over the 4 pre-programme years ( P = 0.89), the increase in hospital deliveries during the 4-year follow-up period in the programme area was 29.3 percentage points (95% CI: 16.1 to 42.6; P < 0.001) greater than the change in the control area (intention-to-treat impact), corresponding to a relative increase in hospital deliveries of 62%. Women who did not enroll in health insurance but who could make use of the upgraded care delivered significantly more often in a hospital during the follow-up period than women living in the control area ( P = 0.04).
  
  
  CONCLUSIONS
  Voluntary health insurance combined with quality healthcare services is highly effective in increasing hospital deliveries in rural Nigeria, by improving access to healthcare for insured and uninsured women in the programme area.
authors.affiliation: Academic Medical Center, Department of Global Health, University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands.
authors.forename: Daniëlla
authors.initials: D
authors.lastname: Brals
authors.affiliation: Department of Epidemiology and Community Health, University of Ilorin Teaching Hospital, Ilorin, Nigeria.
authors.forename: Sunday A
authors.initials: SA
authors.lastname: Aderibigbe
authors.affiliation: Academic Medical Center, Department of Global Health, University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands.
authors.forename: Ferdinand W
authors.initials: FW
authors.lastname: Wit
authors.affiliation: Faculty of Economics and Business, Section Quantitative Economics, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Johannes C M
authors.initials: JCM
authors.lastname: van Ophem
authors.affiliation: Department of Economics, Vrije Universiteit Amsterdam, Amsterdam Institute for International Development, Amsterdam, The Netherlands.
authors.forename: Marijn
authors.initials: M
authors.lastname: van der List
authors.affiliation: Department of Epidemiology and Community Health, University of Ilorin Teaching Hospital, Ilorin, Nigeria.
authors.forename: Gordon K
authors.initials: GK
authors.lastname: Osagbemi
authors.affiliation: Academic Medical Center, Department of Global Health, University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands.
authors.forename: Marleen E
authors.initials: ME
authors.lastname: Hendriks
authors.affiliation: Department of Epidemiology and Community Health, University of Ilorin Teaching Hospital, Ilorin, Nigeria.
authors.forename: Tanimola M
authors.initials: TM
authors.lastname: Akande
authors.affiliation: Academic Medical Center, Department of Global Health, University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands.|Academic Medical Center, Emma Children's Hospital, Department of Paediatrics, Global Child Health Group, Amsterdam, The Netherlands.
authors.forename: Michael
authors.initials: M
authors.lastname: Boele van Hensbroek
authors.affiliation: Academic Medical Center, Department of Global Health, University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands.
authors.forename: Constance
authors.initials: C
authors.lastname: Schultsz
mesh_terms: D000293:Adolescent; D000328:Adult; D036861:Delivery, Obstetric / Q000706:statistics & numerical data*; D005260:Female; D006268:Health Facilities / Q000592:standards; D006761:Hospitals; D006801:Humans; D019458:Insurance Coverage; D007348:Insurance, Health; D008427:Maternal Health Services / Q000706:statistics & numerical data; D008875:Middle Aged; D009549:Nigeria; D011247:Pregnancy; D011787:Quality of Health Care; D012424:Rural Population
keywords: Access to care; Nigeria; global health; health insurance; health system strengthening; hospital delivery; impact evaluation; maternal and new-born health and survival; public health; quality of care; sub-Saharan Africa