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BACKGROUND AND PURPOSE OF RESEARCH: Nigeria’s National Health Insurance Scheme (NHIS) was setup to secure universal access to affordable quality care. However, after 11yrs, and despite launching different programs, NHIS coverage is still less than 3% nationally, and out-of-pocket payments (OOP) remain the major health financing mechanism. The reasons for the low level of enrollment in NHIS are not well understood. Quality of care may be a factor in enrolment. This study compares technical and perceived quality of care between NHIS enrollees and the uninsured, using diabetes as a tracer condition. It also compares OOP and generic prescription patterns by health insurance enrollment status. METHODS: We conducted a cross sectional clinic-based intercept study. Subjects were adult diabetes patients recruited from 10 NHIS accredited hospitals in Abuja, Nigeria. Data collection included survey and chart review, covering technical aspects of quality – performance of eye and feet exam and HbA1c request; perception of quality, generic medication prescribing pattern and OOP. We performed logistic regression analysis to evaluate the effect of NHIS enrollment status on the technical quality of care, perceived quality of care, generic prescribing and OOP. RESULTS: Out of 455 participants, 149 (33%) were NHIS enrollees, 10 (2%) were enrolled in private health insurance and 296 (65%) had no insurance. After adjusting for correlated data and controlling for facility, BMI, chronic disease score, age, sex, and education, patients under NHIS coverage were 0.85 times less likely to have eye exam (Cl=0.4–1.8), 0.98 times less likely to have feet exam (Cl= 0.4–2.2), and 0.98 times less likely to have A1c test requested (Cl= 0.7–1.3), compared to those without insurance. These findings were not statistically significant at alpha=0.05. On the other hand, compared to the uninsured, NHIS covered patients perceived care to be worse even though they spent significantly less, 56% (Cl=45%–69%) in OOP in public hospitals. DISCUSSION/CONCLUSION: Perception of care quality under the NHIS could be a contributory factor to the reluctance of prospective enrollees. To advance towards the goal of universal health coverage, NHIS must strengthen policy to overcome identified barriers such as medication stock outs and wait times at the facility level.

This dissertation addresses gendered vulnerabilities after the genocide of 1994 in Rwanda. It consists of three essays, each focusing on the experience of women in a particular aspect of post-conflict development. The first essay analyzes trends in poverty and inequality in Rwanda from 2000 to 2005. The chapter identifies four important correlates of consumption income: gender, human capital, assets, and geography, and examines their salience in determining the poverty of a household and its position in the income distribution. The second essay is an econometric examination of an important health insurance scheme initiated in post-conflict Rwanda. Employing logistic regression techniques, I find systematically lower membership among female-headed households in the community-based health insurance scheme in Rwanda. This finding contravenes other empirical studies on community-based health insurance in Africa that found higher uptake by female-headed households. Female-headed households are just as likely to access health care, implying greater out-of-pocket expenditures on health. They report worse health status compared to their male counterparts. The third essay examines the prevalence and correlates of intimate partner violence, based on household-level data from the Demographic and Health Survey conducted in Rwanda in 2005. Three results stand out. First, there are significant differences in the prevalence of three different types of gendered violence: physical, emotional and sexual violence. Second, women who are employed but whose husbands are not experience more sexual violence, not less, as would be expected in conventional household bargaining models. This can be interpreted as reflecting `male backlash' as gender norms are destabilized. Finally, there is a strong inter-district correlation between the post-conflict prevalence of sexual violence and the intensity of political violence during the genocide. The findings of the dissertation support its underlying premise: that looking at economic processes through a gendered lens, and recognizing that women face social, historical and institutional constraints that are ignored in much standard economic theorizing, affords important insights into social processes and development outcomes.

Purpose - The thesis determined how policy implementation and change management can be improved in Nigeria, with the health insurance scheme as the basis for narrative exploration. It sets out the similarities and differences in assumptions between supra-national organisations such as the World Bank and World Health Organisation on policy implementation and change management and those contained in the Nigerian national health policy; and those of people responsible for implementation in Nigerian organisations at a) the federal or national level and b) at sub-federal service delivery levels of the health insurance scheme. The study provides a framework of the dimensions that should be considered in policy implementation and change management in Nigeria, the nature of structural and infrastructural problems and wider societal context, and the ways in which conceptions of organisations and the variables that impact on organisations¿ capability to engage in policy implementation and change management differ from those in the West. Design/methodology/approach - A qualitative approach in the form of a case study was used to track the transformation of a policy into practice through examining the assumptions and expectations about policy implementation of the organisations financing the policy's implementation through an examination of relevant documents concerning policy, strategy and guidelines on change management and policy implementation from these global organisations, and the Nigerian national health policy document. The next stages of field visits explored the assumptions, expectations and experiences of a) policy makers, government officials, senior managers and civil servants responsible for implementing policy in federal-level agencies through an interview programme and observations; and b) those of sub-federal or local-level managers responsible for service-level policy implementation of the health insurance scheme through an interview programme. Findings - There are conflicts between the rational linear approaches to change management and policy implementation advocated by supra-nationals, which argue that these processes can be controlled and managed by the rational autonomous individual, and the narratives of those who have personal experience of the quest for 'health for all'. The national health policy document mirrors the ideology of the global organisations that emphasise reform, efficiencies and private enterprise. However, the assumptions of these global organisations have little relevance to a Nigerian societal and organisational context, as experienced by the senior officials and managers interviewed. The very nature of organisations is called into question in a Nigerian context, and the problems of structure and infrastructure and ethnic and religious divisions in society seep into organisations, influencing how organisation is enacted. Understandings of the purpose and function of leadership and the workforce are also brought into question. Additionally, there are religion-based barriers to policy implementation, change management and organisational life which are rarely experienced in the West. Furthermore, in the absence of future re-orientation, the concept of strategy and vision seems redundant, as is the rationale for a health insurance scheme for the majority of the population. The absence of vision and credible information further hinder attempts to make decisions or to define the basis for determining results. Practical implications - The study calls for a revised approach to engaging with Nigerian organisations and an understanding of what specific terms mean in that context. For instance, the definitions and understanding of organisations and capacity are different from those used in the West and, as such, bring into question the relevance and applicability of Western-derived models or approaches to policy implementation and change management. A framework with four dimensions - societal context, external influences, seven organisational variables and infrastructural/structural problems - was devised to capture the particular ambiguities and complexities of Nigerian organisations involved in policy implementation and change management. Originality/value - This study combines concepts in management studies with those in policy studies, with the use of narrative approaches to the understanding of policy implementation and change management in a Nigerian setting. Elements of culture, religion and ethical values are introduced to further the understanding of policy making and implementation in non-Western contexts.

This thesis sheds light on differences in health insurance enrolment determinants and uptake barriers between urban and rural areas in the Jirapa district of Ghana. The National Health Insurance Scheme in Ghana has made significant progress in terms of enrolment, which has had a commensurate increase in utilization of health care services. However, there are challenges that pose a threat to the scheme’s transition to universal coverage; enrolment in the scheme has not progressed according to plan, and there are many barriers known to impede uptake of health care. Interestingly, these barriers vary in relation to locality, and rural residents appear to carry a disproportionate portion of the burden. A mixed method approach was employed to collect and analyse the data. On the basis of the primary qualitative and quantitative results, the thesis argues that the costs of enrolling and accessing health care is disproportionately higher for rural residents than it is their urban counterparts. It also highlights that the distribution of service benefits both in terms of the NHIS and health care in the Jirapa district favours urban residents. Lastly, the thesis found that whereas rural residents prefer health care provision to be social in nature, urban residents were more interested in the technical quality aspects of care. These findings suggest that rural residents are not benefitting from, or may not be accessing health services to the extent as their urban counterparts. Affordability, long distance to health facilities, availability and acceptability barriers were found to influence the resultant pro-urban distribution of the overall health care benefit. / Ghana Education Trust Fund (GETFund)

The purpose of this study was to investigate the relationship between health insurance status and diabetes management (in terms of medication adherence and physical activity levels) in Black adults based on socioeconomic factors. Data were harvested from the Sample Adult Questionnaires of the National Health Interview Survey (NHIS) between the years of 2010 and 2016. The survey questions that were collected included information about the participants' income, education level, insurance status, diabetes diagnosis, medication therapy and physical activity levels. This study employed the most recent version of the Statistical Package for Social Sciences (SPSS) software. The association between diabetes management and socioeconomic factors were analyzed using chi-square analysis. It was hypothesized that Black adults who were uninsured, lower income, and less-educated would report lower adherence to medication and lower physical activity participation when compared to their insured, higher income, and higher-educated counterparts. However, there was no statistically significant relationship between health insurance status and diabetes management in people of different socioeconomic status. Too few people met the weekly recommendations for moderate exercise thus chi-square outcomes for physical activity were invalid. This study will be beneficial for future research as it has provided more generalizable information on this topic due to the use of a national dataset. This study also highlighted the importance of adequate physical activity interventions for this population and can be used for further research on Black adults with diabetes.

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