Evaluating the Impact of Kano State Contributory Healthcare Management Agency Integration of HIV Prevention, Treatment, and Lifelong Care on Healthcare Access and Financial Sustainability in Kano State, Nigeria: A Mixed-Methods Study

Technical Summary: Evaluating the Impact of Kano State Contributory Healthcare Management Agency (KSCHMA) Integration of HIV Services

Problem Statement
The global response to HIV is shifting from vertically funded, donor-dependent emergency systems to integrated national health systems supporting Universal Health Coverage (UHC). In Sub-Saharan Africa, particularly Nigeria, the contraction of funding from major donors (e.g., Global Fund, PEPFAR) necessitates the integration of HIV services into domestic health financing architectures. Kano State, Nigeria's most populous state, faces a dual challenge: a high burden of HIV and severe constraints in healthcare delivery. Historically, HIV services were delivered through vertical facilities, resulting in fragmented care, high out-of-pocket expenditures (OOPE) for patients traveling long distances, and vulnerability to donor funding shifts. While the Kano State Contributory Healthcare Management Agency (KSCHMA) was established in 2016 to expand health insurance coverage, there is a lack of empirical evidence regarding the impact of integrating HIV prevention, treatment, and lifelong care into this social health insurance scheme. Specifically, gaps exist in understanding the effects on healthcare access, financial protection, service quality, and the long-term fiscal sustainability of such integration.

Methodology
This study employed a convergent parallel mixed-methods design (quantitative cross-sectional and qualitative phenomenological) conducted between October and December 2025.

• Setting: 27 randomly selected healthcare facilities across three senatorial districts in Kano State, comprising 9 secondary facilities and 18 Primary Health Care (PHC) centers.
• Quantitative Component: Data were collected from 422 People Living with HIV (PLHIV) enrolled in KSCHMA for at least six months. A multi-stage cluster sampling technique was used. Data collection utilized structured questionnaires to capture demographics, OOPE, catastrophic health expenditure (CHE), travel metrics, adherence rates, and satisfaction scores, comparing pre- and post-integration metrics. Statistical analysis involved paired t-tests, Wilcoxon signed-rank tests, and Chi-square tests using IBM SPSS version 26.
• Qualitative Component: Key Informant Interviews (KIIs) were conducted with 24 participants, including 8 KSCHMA administrators (executive leaders, actuarial planners, claims directors) and 16 facility managers. Semi-structured guides focused on financial liquidity, reimbursement timelines, supply chain stability, and policy implementation hurdles. Data were analyzed using thematic framework analysis in NVivo.
• Evaluation Framework: The study utilized a standardized Evaluation Indicator Matrix covering four domains: Financial Protection, Clinical/Service Coverage, Operational/Administrative Efficiency, and Fiscal/Scheme Solvency.

Key Results
The integration of HIV services into KSCHMA yielded significant improvements in access and financial protection, though operational and fiscal challenges remain.

1. Financial Protection:

   • Out-of-Pocket Expenditure (OOPE): Reduced by 72.4%, from a median of ₦4,544 pre-integration to ₦1,256 post-integration ($p<0.001$).
   • Catastrophic Health Expenditure (CHE): The proportion of households experiencing CHE (spending >10% of income) dropped from 71.3% to 27.0% ($p<0.001$).
   • Impoverishment: The rate of impoverishment due to health costs decreased from 41.0% to 34.1% ($p<0.001$).

2. Access and Clinical Outcomes:

   • Geographic Access: Median travel distance to care decreased from 48 km to 22 km; 47.8% of patients could now access ART refills within their Local Government Area.
   • Adherence and Suppression: Missed ART refills decreased by 47.8% (from 27.2% to 14.2%). Viral load suppression rates (<50 copies/mL) increased significantly from 47.4% to 78.2% ($p<0.001$).
   • Satisfaction: Patient satisfaction rose from 56.4% to 79.6% ($p<0.001$).

3. Operational Efficiency:

   • Reimbursement Delays: The average time from claim submission to reimbursement was 69 days, significantly exceeding the 30-day target.
   • Stockouts: These delays correlated with a 45% stockout rate for non-ART supplies at facilities, threatening comprehensive care models.

4. Fiscal Sustainability:

   • Claims-to-Premium Ratio: The HIV-specific claims-to-premium ratio was found to be 2.24 (noted as 1.32 in one section, but 2.24 in the abstract and discussion as the critical unsustainable figure), indicating that current premium structures cannot cover the cost of lifelong HIV care without external subsidies.
   • Donor Dependency: The scheme relies heavily on donor funding for high-cost items (e.g., second-line ART, reagents), creating a risk of an "actuarial cliff" as donor support contracts.

Qualitative Themes
Thematic analysis revealed three core realities:

• Decentralisation as an Access Catalyst: Integrating HIV into primary care broke down vertical silos, reduced stigma, and improved geographic access.
• Liquidity Constraints and Claims Friction: Administrative bottlenecks and manual claim verification processes caused severe reimbursement delays, leading to supply chain instability for non-ART commodities.
• The Actuarial Cliff: Administrators expressed concern that the current premium model, designed for acute primary care, is structurally unsuited for the lifelong, high-cost burden of chronic HIV management, especially as donor funding declines.

Significance and Claims
The paper claims to provide the first empirical evidence in Kano State regarding the multi-stakeholder impact of integrating HIV services into a state health insurance scheme. Its significance lies in:

• Demonstrating Financial Protection: Proving that social health insurance can effectively shield PLHIV from catastrophic health expenditures and impoverishment in a low-resource setting.
• Validating Decentralization: Showing that shifting ART delivery to PHCs improves access and clinical outcomes (viral suppression) while reducing travel burdens.
• Identifying Structural Risks: Highlighting that while clinical and access metrics are positive, the scheme's long-term solvency is threatened by actuarial deficits and administrative inefficiencies.
• Policy Guidance: The study argues that for such integration to be sustainable, it requires actuarial re-basing of premiums, specific state subsidies (including from the Basic Health Care Provision Fund), and the automation of claims processing to ensure liquidity. It posits that without these structural reforms, the scheme risks collapse as donor support transitions.

The authors conclude that while integration is a successful strategy for improving access and financial protection, it is not self-sustaining under current financing models and requires targeted domestic funding reforms to survive the transition away from donor reliance.