Geographic and Socioeconomic Disparities in Social Health Insurance Enrolment: Understanding the Barriers and Facilitators to Achieving Universal Health Coverage
DOI:
https://doi.org/10.54536/ajmhc.v1i2.7122Keywords:
Enrolment Uptake, Equity Fund, Geographic Disparities Social Health Insurance, Universal Health CoverageAbstract
The social health insurance (SHI) program in Bayelsa State, Nigeria, aimed to promote universal health coverage but faced significant geographic and socioeconomic barriers that hindered enrolment and access to healthcare services. Prior studies indicated disparities in enrolment based on distance to centres, income levels, and administrative challenges, yet specific insights into these barriers within the unique context of Bayelsa remained limited. This study sought to understand how geographic, socioeconomic, and administrative factors influenced enrolment in Bayelsa State’s social health insurance program and to assess the implications for achieving universal health coverage. A cross-sectional, mixed-methods design was employed, involving data collection from 600 residents aged 19 years and older across eight local government areas. Structured questionnaires were administered to capture demographic, socioeconomic, and geographic data, as well as insights into enrolment processes and barriers. Statistical analyses, including logistic regression and chi-square tests, were performed to identify relationships between enrolment status and various predictors. The findings revealed significant geographic disparities in enrolment, with 76% of respondents living over 20 kilometers from enrolment centres. Socioeconomic factors also played a crucial role: higher household income was associated with higher enrolment rates, while barriers such as the lack of national identity cards and travel costs impeded access for lower-income individuals. The analysis highlighted that urban residents were more likely to enroll than their rural counterparts, and educational attainment significantly influenced enrolment likelihood. The study concluded that multifaceted barriers geographic isolation, economic precarity, and administrative inefficiencies significantly impacted enrolment in Bayelsa’s social health insurance program. Targeted interventions, including mobile enrolment units, simplified documentation processes, and subsidies for low-income individuals, were recommended to enhance access and advance universal health coverage for marginalized populations in the state.
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Aboagye, R. G., Boateng, E. N. K., Okyere, Y. M., Okyere, J., Dickson, K. S., Seidu, A. A., & Ahinkorah, B. O. (2023). Spatial distribution and factors associated with health insurance subscription among women in Ghana. International Health, 16(6), 610–624. https://doi.org/10.1093/inthealth/ihad092
Adegboye, O. D., Fasiku, M. M., Olusola Ibirongbe, D., & Akande, T. M. (2023). Experience of Health Shocks and Uptake Of Health Insurance in Rural and Urban Communities, North Central Nigeria: A Qualitative Study. International Journal of Health Sciences, 11(2), 2372–5079. https://doi.org/10.15640/ijhs.v11n2a8
Adekunle, W., & Vincent, O. (2025). Analysing the determinants of healthcare insurance uptake in Nigeria. BMC Health Services Research, 25(1). https://doi.org/10.1186/s12913-025-13422-0
Ajemunigbohun, S. S., Adeola Banjo, K., & Saka, T. S. (2022). Insurance Literacy and Risk Appetite: Evidence from Selected Small and Medium-Sized Enterprises in Lagos, Nigeria. ACTA UNIVERSITATIS DANUBIUS, 18(5), 2022.
Alnajjar, M. I. (2024). The Impact of Unified Medical Insurance System Implementation (Nphies) on Healthcare Service Quality: Applied Research Case Study in Arrawdha General Hospital Dammam, Saudi Arabi. American Journal of Medical Science and Innovation, 3(1), 118–133. https://doi.org/10.54536/ajmsi.v3i1.2630
Asabere, N. Y., Asare, I. O., Lawson, G., Balde, F., Duodu, N. Y., Tsoekeku, G., Afriyie, P. O., & Ganiu, A. R. A. (2024). Geo-Insurance: Improving Big Data Challenges in the Context of Insurance Services Using a Geographical Information System (GIS). Human Behavior and Emerging Technologies, 2024. https://doi.org/10.1155/2024/9015012
Banke-Thomas, A., Olubodun, T., Olaniran, A. A., Wong, K. L. M., Shah, Y., Achugo, D. C., & Ogunyemi, O. (2024). Optimising availability and geographical accessibility to emergency obstetric care within a sub-national social health insurance scheme in Nigeria. Frontiers in Health Services, 4. https://doi.org/10.3389/frhs.2024.1460580
Cu, A., Meister, S., Lefebvre, B., & Ridde, V. (2021). Assessing healthcare access using the Levesque’s conceptual framework– a scoping review. International Journal for Equity in Health, 20(1). https://doi.org/10.1186/s12939-021-01416-3
Eibner, C., Cordova, A., Nowak, S. A., Price, C. C., Saltzman, E., & Woods, D. (2013). The Affordable Care Act and Health Insurance Markets: Simulating the Effects of Regulation. www.rand.org
Ekubu Otim, M., Pannarunothai, S., Tafadzwa Lukwa, A., Husni Jamal, M., Firzah Abdul Aziz, A., Noor Aizuddin, A., & Mohamed Aljunid, S. (2022). Successes and obstacles in implementing social health insurance in developing and middle-income countries: A scoping review of f-year recent literatures. Frontiers in Public Health. https://doi.org/https://doi.org/10.3389/fpubh.2022.918188
Ellegård, L. M., & Laberge, M. (2025). Risk Adjustment in Capitation Payments to Primary Care Providers Does It Matter How We Account for Patients’ Socioeconomic Status? Medical Care, 63(6), 430–435. https://doi.org/10.1097/MLR.0000000000002141
Elomari, R. (2025). The Long-Term Relationship between Insurance Customers and Agents: The Importance of Full Disclosure for Optimal Coverage. American Journal of Economics and Business Innovation, 4(1), 11–19. https://doi.org/10.54536/ajebi.v4i1.3095
Emmanuel Bamidele, B., & Michael Nda, M. (2023). Analysis of Factors that Enhance Insurance Penetration in Rural Areas in Imo State Nigeria. International Journal of Insurance, 1(11). https://journals.unijos.edu.ng/index.php/ijirms
Franke, M. A., Adzeley Boi-Dsane, N. A., Lubajo, R., Yerima, A., Sarabu, S., & Kobla Latey, A. D. (2026). Faith-based organisations and religious affiliation and their interactions with financial risk protection in health in Sub-Saharan Africa: A systematic review. In Public Health (Vol. 250). Elsevier B.V. https://doi.org/10.1016/j.puhe.2025.106014
Galárraga, O., Sosa-Rubí, S. G., Salinas-Rodríguez, A., & Sesma-Vázquez, S. (2010). Health insurance for the poor: Impact on catastrophic and out-of-pocket health expenditures in Mexico. European Journal of Health Economics, 11(5), 437–447. https://doi.org/10.1007/S10198-009-0180-3
George Anarwat, S. (2022). Health Insurance for Economically Disadvantaged People in LMICs: What are the Best Options? In Health Insurance. IntechOpen. https://doi.org/10.5772/intechopen.105679
Gharakhani, M., & Pourhashemi, S. O. (2020). Adoption of Mobile insurance technology using TAM: A Case Study. International Journal of Industrial Engineering & Management Science, 8(2), 45–54.
Handayani, R., Nurmiati, Susanti, & Mahadewi, P. E. (2023). The Impact of Economic And Social Factors On Demand For Health Insurance: Case Study of Metropolitan Cities. International Journal of Health and Pharmaceutical. https://ijhp.net
Ho, Y., & -Okafor, K. (2019). Health Insurance Knowledge, Attitude and Uptake of the Community Based Health Insurance Scheme Among Residents of a Suburb in Lagos, Nigeria. The West African Journal of Medicine, 36(2), 103–111.
Hosseinpoor, A. R., Victora, C. G., Bergen, N., Barros, A. J. D., & Boerma, T. (2011). Towards universal health coverage: The role of within-country wealth-related inequality in 28 countries in sub-Saharan Africa. Bulletin of the World Health Organization, 89(12), 881–890. https://doi.org/10.2471/BLT.11.087536
IAIS. (2004). Insurance Core Principles on Corporate Governance.
Krzyż, E. Z., Antunez Martinez, O. F., & Lin, H. R. (2023). Uses of Andersen health services utilization framework to determine healthcare utilization for mental health among migrants—a scoping review. Frontiers in Public Health, 11. https://doi.org/10.3389/fpubh.2023.1284784
Levesque, J. F., Harris, M. F., & Russell, G. (2013). Patient-centred access to health care: Conceptualising access at the interface of health systems and populations. International Journal for Equity in Health, 12(1), 18. https://doi.org/10.1186/1475-9276-12-18
Limiri, D. M. (2025). The Impact of Long Wait Times on Patient Health Outcomes: The Growing NHS Crisis. Premier Journal of Public Health. https://doi.org/10.70389/pjph.100020
Magambo, J., Warue, B., Mbugua, L., & Mwenja, D. (2022). Social Capital and Health Micro-Insurance Uptake by the Informal Sector Workers in Kenya. The University Journal, 4(1), 2519–0997.
Manan, N., Idham Abu Hasan, N., Jamal, N. F., & Abu Hasan, N. (2021). Development of VBA Program for Affordable Premium and Coverage for Lower Income Group in Malaysia. International Journal of Academic Research in Business and Social Sciences, 11(8). https://doi.org/10.6007/ijarbss/v11-i8/10745
Marquis, M. S., & Buntin, M. B. (2006). How much risk pooling is there in the individual insurance market? Health Services Research, 41(5), 1782–1800. https://doi.org/10.1111/j.1475-6773.2006.00577.x
Meenaghan, T. M., & Washington, R. O. (1980). Social Policy and Social Welfare Structure and Applications (First Edition). The Free Press.
Mhoja, N., & Lihoya, C. (2024). Factors Influencing Civil Servants’ Perceptions of National Health Insurance Schemes: A Case Study of the Tanzania Industrial Research and Development Organization (TIRDO), Tanzania. African Journal of Empirical Research, 5(3), 1257–1267. https://ajernet.net
Nay, O., Béjean, S., Benamouzig, D., Bergeron, H., Castel, P., & Ventelou, B. (2016). Achieving universal health coverage in France : policy reforms and the challenge of inequalities. The Lancet, 2236–2249. https://doi.org/10.1016/S0140-6736(16)00580-8ï
NPC. (2022). Bayelsa Population Census. https://citypopulation.de/en/nigeria/admin/NGA006__bayelsa/
Olaosun, O. M. (2025). Socio-Economic Factors and the Demand for Insurance: A Study of Selected Sole-Proprietorship in Lagos Metropolis. International Journal of Finance, Insurance, and Risk Management, XV(3), 37–52.
Radhamony, R., Cross, W. M., Townsin, L., & Banik, B. (2024). Culturally and Linguistically Diverse Community Access and Utilisation of the Mental Health Service: An Explanation Using Andersen’s Behavioural Model. Issues in Mental Health Nursing, 45(7), 758–765. https://doi.org/10.1080/01612840.2024.2359602
Raichle, W. M. (2023). Insurance Geographies.
Smith, P. C., & Witter, S. N. (2004). Risk Pooling in Health Care Financing: The Implications for Health System Performance.
Solomon Fadun, O. (2013). Corporate Governance and Insurance Company Growth: Challenges and Opportunities. International Journal of Academic Research in Economics and Management Sciences, 2(1). www.hrmars.com
Stock, R. (1983). Distance and the utilization of health facilities in rural Nigeria. Social Science & Medicine, 17(9), 563–570. https://doi.org/10.1016/0277-9536(83)90298-8
Sultana, Most. S., & Ali, Md. S. (2025). Hardship Financing in Healthcare among Rural Residents in the Gaibandha District: An Application of Binary Logistic Regression. American Journal of Economics and Business Innovation, 4(2), 280–290. https://doi.org/10.54536/ajebi.v4i2.5387
Tanser, F., Gijsbertsen, B., & Herbst, K. (2006). Modelling and understanding primary health care accessibility and utilization in rural South Africa: An exploration using a geographical information system. Social Science and Medicine, 63(3), 691–705. https://doi.org/10.1016/j.socscimed.2006.01.015
Thaddeus, S., & Maine, D. (1994). Too far to walk: Maternal mortality in context. Social Science and Medicine, 38(8), 1091–1110. https://doi.org/10.1016/0277-9536(94)90226-7
Treaty Commission, B. (2024). First Nations Eligibility & Enrolment 2024. BC Treaty Commission. www.bctreaty.ca.
Wagstaff, A. (2010). Social health insurance reexamined. Health Economics, 19(5), 503–517. https://doi.org/10.1002/HEC.1492
Williams, J. U., & Tesunbi, S. (2025). Strategic Financial Risk Management and Organizational Effectiveness in NEM Insurance Plc Lagos Nigeria. Journal of Entrepreneurship & Business Strategies, 1(1). https://journals.e-palli.com/home/index.php/jebs
York, R., Moreno-Serra, S., Phd, ) ;, São, P., Hone, T., Gonçalves, J., Seferidi, P., Moreno-Serra, R., Rocha, R., Gupta, I., Bhardwaj, V., Hidayat, T., Cai, C., Suhrcke, M., & Millett, C. (2024). Progress towards universal health coverage and inequalities in infant mortality: an analysis of 4•1 million births from 60 low-income and middle-income countries between 2000 and 2019. Lancet Glob Health, 12, e744-55. www.thelancet.com/lancetgh
Yuan, Z., Zhang, F., Li, Z., & Wei, H. (2024). Urban-Rural Health Insurance Integration and China’s Rural Household Savings. Risk Management and Healthcare Policy, 17, 587–601. https://doi.org/10.2147/RMHP.S451278
Zhou, Y., & Ping, J. (2024). Impact of urban–rural resident basic medical insurance on consumption quality of middle-aged and older adult residents: evidence from rural China. Frontiers in Public Health, 12. https://doi.org/10.3389/fpubh.2024.1374552
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