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Original Investigation |

Effect of Health Insurance and Facility Quality Improvement on Blood Pressure in Adults With Hypertension in Nigeria:  A Population-Based Study

Marleen E. Hendriks, MD1; Ferdinand W. N. M. Wit, MD, PhD1; Tanimola M. Akande, MD2; Berber Kramer, PhD3,4; Gordon K. Osagbemi, MD2; Zlata Tanović, MSc4; Emily Gustafsson-Wright, PhD4,5; Lizzy M. Brewster, MD, PhD6,7; Joep M. A. Lange, MD, PhD1; Constance Schultsz, MD, PhD1
[+] Author Affiliations
1Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
2Department of Epidemiology and Community Health, University of Ilorin Teaching Hospital, Ilorin, Nigeria
3Markets, Trade and Institutions Division, International Food Policy Research Institute, Washington, DC
4Amsterdam Institute for International Development, Free University, Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
5Center for Universal Education, Brookings Institution, Washington, DC
6Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
7Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
JAMA Intern Med. 2014;174(4):555-563. doi:10.1001/jamainternmed.2013.14458.
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Importance  Hypertension is a major public health problem in sub-Saharan Africa, but the lack of affordable treatment and the poor quality of health care compromise antihypertensive treatment coverage and outcomes.

Objective  To report the effect of a community-based health insurance (CBHI) program on blood pressure in adults with hypertension in rural Nigeria.

Design, Setting, and Participants  We compared changes in outcomes from baseline (2009) between the CBHI program area and a control area in 2011 through consecutive household surveys. Households were selected from a stratified random sample of geographic areas. Among 3023 community-dwelling adults, all nonpregnant adults (aged ≥18 years) with hypertension at baseline were eligible for this study.

Intervention  Voluntary CBHI covering primary and secondary health care and quality improvement of health care facilities.

Main Outcomes and Measures  The difference in change in blood pressure from baseline between the program and the control areas in 2011, which was estimated using difference-in-differences regression analysis.

Results  Of 1500 eligible households, 1450 (96.7%) participated, including 564 adults with hypertension at baseline (313 in the program area and 251 in the control area). Longitudinal data were available for 413 adults (73.2%) (237 in the program area and 176 in the control area). Baseline blood pressure in respondents with hypertension who had incomplete data did not differ between areas. Insurance coverage in the hypertensive population increased from 0% to 40.1% in the program area (n = 237) and remained less than 1% in the control area (n = 176) from 2009 to 2011. Systolic blood pressure decreased by 10.41 (95% CI, −13.28 to −7.54) mm Hg in the program area, constituting a 5.24 (−9.46 to −1.02)–mm Hg greater reduction compared with the control area (P = .02), where systolic blood pressure decreased by 5.17 (−8.29 to −2.05) mm Hg. Diastolic blood pressure decreased by 4.27 (95% CI, −5.74 to −2.80) mm Hg in the program area, a 2.16 (−4.27 to −0.05)–mm Hg greater reduction compared with the control area, where diastolic blood pressure decreased by 2.11 (−3.80 to −0.42) mm Hg (P = .04).

Conclusions and Relevance  Increased access to and improved quality of health care through a CBHI program was associated with a significant decrease in blood pressure in a hypertensive population in rural Nigeria. Community-based health insurance programs should be included in strategies to combat cardiovascular disease in sub-Saharan Africa.

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Participation in the 2009 and 2011 Surveys and Reasons for Attrition

aKey variables include age, sex, consumption (measured in per capita US dollars), and/or wealth indicator.

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