It was surprising to find that very few individuals had consumed wholly free services. This is despite the purported widespread availability in the study area of free immunisation services and malaria treatment services for pregnant women and children under-five. The finding that immunisation services were the most commonly used free service, followed distantly by Insecticide Treated Nets (ITNs) and antimalarial drugs was expected since immunisation of children through the National Programme on Immunisation is implemented on a wide scale in the fight to eradicate polio in the country. Through the availability of free ITNs and artemisinin-based combination therapy (ACTs) through the Global Fund to Fight AIDS, TB and Malaria, these malaria control tools should be widely deployed. However, this study shows that procurement and deployment of the materials by the government and development partners to health facilities and government stores do not mean that they actually reach the people.
A positive finding was that the consumption of antimalarial drugs and tuberculosis (TB) services was pro-poor, and pro-rural. However, the distribution of ITNs and free antenatal care (ANC) both favoured the better off quintiles, and urban populations. A previous study in Nigeria found that urban dwellers received more antimalarial drugs compared to rural dwellers, but rural dwellers owned more ITNs compared to the urbanites, which is contrary to the results from this study but the reasons for the disparity are not clear. It is generally accepted that government health expenditures should disproportionately benefit the poor. And yet in most developing countries the opposite is the case. To the extent that need is greater among poor and among rural communities, this reflects an equitable distribution. Some of the results are unlike an analysis in Asia that showed that the distribution of public healthcare is pro-rich in most developing countries.
The utilisation that is reported of free services is potentially a mix of public and private utilisation since the questionnaire did not differentiate between the two, and BIA is about the incidence of public subsidies. However, it is almost impossible to find utilisation of free services in the private sector, hence, we can be almost 100% sure that reported utilisation of free services occurred entirely in the public sector and does really represent public subsidies. Nonetheless, a note of caution should still be maintained that the benefits measured could be slightly overestimating actual benefits. However, in the case of immunisation services, the assumption that free services are provided in the public sector are more likely to hold and BIA of consumption of free immunisation services may in actual fact represent the net benefit of public subsidies for such services. It is only in the private sector that people pay to have immunisation. The results showed negative net benefits for those services that are also provided by the private sector: drugs for treatment of malaria, ANC and childbirth services.
It was also found that some people spent money on services that are supposed to be free including, immunisation services, ITNs, anti-malaria drugs, ANC, child birth services, ARV, FP services and treatment of TB. More money was generally spent for all services in the urban areas except for child birth services compared to rural areas. However, compared to their share of the total population, the rural dwellers spent more money on four of the services indicating a greater burden to access public health services on the rural dwellers. There was also more expenditure amongst better-off SES quintiles compared to their share of the total population. The money that was paid for the supposedly free public health services may due to the imposition of formal user charges, private sector use of these services, or some degree of informal charging.
There was no clear underlying reason for the disparity in benefit incidence of the various public health services to different sexes and people living in urban and rural areas. However, the fact that pregnant women receive free ITNs and anti-malarial drugs from public health facilities could have contributed to their capturing higher benefits for those commodities. The finding that compared to their share in the population, rural dwellers marginally consumed more immunisation services and anti-malarial drugs and TB treatment services compared to urban dwellers was reassuring for control of the diseases, because usually people residing in rural areas lack access to healthcare services. However, the finding that urbanites consumed more of free ITNs and ANC services could be as a result of concentration of net distribution outlets and public health facilities in the urban areas.
The fact that the better-off SES consumed more of ITNs and ANC, represents inequity in the deployment of the two essential free services, which should be corrected using appropriate strategies. The 2008 NDHS also reported inequalities in ownership of ITNs, consumption of antimalarial drugs and ANC favouring the better off. Also, the explanation for the greater benefit incidence for treatment of TB by the poorer SES groups is clear since TB is a disease of poverty. However, the reasons for the inequity in the others are less clear, but could be due to the ‘law of inverse equity’[20, 21], where the rich capture more of the benefits of publicly provided services when coverage is low, and that as coverage increases the poor will then start benefiting equally. It could also be due to higher formal and informal political activism by the beneficiaries, as it has been found that individuals with higher political activism have better access to health services than others.
The finding that more urbanites spent money on most public health services except for treatment of TB compared to rural dwellers is probably because the services were more available in the urban areas and the urbanites also had more stable disposable income to spend on the health services. There are also higher cost providers in the urban areas. In addition, it is reasonable that females that had more access to services paid more, although it was surprising to discover females paid for services that are free to those that are pregnant. Also, the significant finding that payment for immunisation services increased as SES increased is probably an income effect. People that have more money were more willing to pay to receive the essential services. An implication is that the better-off are getting the services in places they have to pay. When viewed from the point that most of the services have externalities, the negative influences on non-coverage of all the needy people become worrisome. Nonetheless, while the rich are more likely to pay than the poor, the fact that the poor are as likely to use suggests that the immunisation programme is working.
One limitation of the study is that the one-month and six-month (for some priority free services) recall periods may not lead to very accurate collection of data on household health expenditures and consumption of some free services. Also, the questionnaire did not differentiate between public and private service provision and costs because the free services are almost entirely provided by the public sector, but may be delivered by the private sector, thus necessitating strong assumptions about patterns of use and expenditures. For instance, government uses private sector providers to deliver immunisation services in many remote parts of Nigeria by supplying them vaccines and syringes free of charge. was Also, the fact that our survey did not distinguish between pregnant and non-pregnant women beneficiaries in BIA to allow for a more robust conclusion about whether free services for pregnant are really free to them is a study limitation. It did not also examine relative need for services or outcomes. Another possible limitation of the study was we only examined the distribution of benefits for a limited range of public health services. Although the information presented is very useful for programmatic purposes, it may not provide a full set of information required by policymakers to have the full picture about the population groups that benefit from public expenditures. Such comprehensive information will help in holistically ensuring that public expenditures are equitably consumed by different population groups, especially in terms of ensuring vertical equity.
In computing BIA, future studies should investigate use and cost of public services at different levels of health facility, and be able to disaggregate consumption of public subsidies by age-groups and whether women were pregnant or not and identify public sector utilization. This is especially important in case of immunisation services where different vaccines are given at different times and depending on whether or not a woman is pregnant. These will require more specific unit costs to be used in the computation of benefits. It will also be important to understand whether the payments for supposedly free public health services are legal or illegal. Also, future studies should attempt to compute unit costs from private and public sources and use them to value the benefits of services that are delivered through the different sectors. Furthermore, the indirect costs of consumption of services from different providers should be computed to explain further reasons why people would opt for the private sector where they will pay some money instead of the private sector where they may not have to pay any fee to consume the services.
Overall, it was reassuring to find that the poor gained more aggregate net benefits from priority public healthcare services and net benefits decreased as SES quintile increased. This also implies that if the coverage with these services is increased, the poor will benefit more and will be prevented from developing many diseases, most of which lead to their incurring impoverishing catastrophic health expenditures. However, the low and inequitable coverage with public health services, possible illegal payments, that could have further decreased access to the public health services are areas that require programmatic and policy interventions to address. The reasons that were provided by the 2008 National Demographic Health Survey (NDHS) why many children were not receiving immunisations included lack of information, fear of side effects and the venue for immunisation being located too far away. The benefit incidence analysis framework is a useful tool for informing resource allocation decision-making in order to ensure equity of government spending on priority public health services. The government and development partners should develop ways and means of scaling-up the free distribution of vital public health services, whilst developing and implementing strategies that will be used to decrease private payments for such services. The services should be viewed as public goods with externalities and illegal payments which probably hindered access to their consumption will lead to negative consequences.