A Scoping Review of the Impact of State-Developed Health Insurance Schemes on Healthcare Accessibility, Financial Stability, and Healthcare Outcomes: A Focus on ILERA EKO, a Lagos State Insurance Initiative, Nigeria

A Scoping Review of the Impact of State-Developed Health Insurance Schemes on Healthcare Accessibility, Financial Stability, and Healthcare Outcomes: A Focus on ILERA EKO, a Lagos State Insurance Initiative, Nigeria | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review A Scoping Review of the Impact of State-Developed Health Insurance Schemes on Healthcare Accessibility, Financial Stability, and Healthcare Outcomes: A Focus on ILERA EKO, a Lagos State Insurance Initiative, Nigeria Michael Oluwole Ogunkoya, Whenayon Oluwasegun Sanusi, Grace Damilola Ogunkoya, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7511689/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 4 You are reading this latest preprint version Abstract Introduction Health insurance schemes are fundamental in mitigating financial healthcare barriers and advancing universal health coverage (UHC); however, Nigeria faces low enrollment rates, with over 70% of healthcare expenditures being funded through out-of-pocket payments. This study evaluates the impact of Lagos State’s ILERA EKO Health Insurance Scheme, a state-led initiative launched in 2022, on healthcare accessibility, financial protection, and health outcomes, offering insights into its role within Nigeria’s fragmented health system. Methodology A scoping review was conducted following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) framework. Systematic searches across PubMed, Scopus, CINAHL, and grey literature (e.g., Lagos State government reports, World Bank documents) identified 780 studies, with 11 meeting inclusion criteria focusing on themes such as enrollment barriers, equity in access, and governance challenges. Results ILERA EKO improved healthcare access for low-income populations, with insured individuals reporting 40% lower out-of-pocket expenditures. Maternal health services and chronic disease management saw notable gains, including increased antenatal care attendance. However, enrollment remains low (15% coverage), hindered by bureaucratic inefficiencies, limited public awareness, and funding gaps. Geographic disparities persist, with rural Lagos residents facing persistent access barriers despite the scheme’s objectives. Discussion While ILERA EKO shows a strong indication as a tool for financial risk protection, its impact is constrained by structural challenges, including fragmented funding and inadequate integration with private providers. Lessons from Ghana’s NHIS suggest that decentralizing enrollment and leveraging community health workers could improve adoption. Future research should prioritize mixed-methods evaluations to assess long-term health outcomes and cost-effectiveness. Policymakers must address administrative bottlenecks and expand public awareness campaigns to realize the scheme’s UHC ambitions in Lagos State and comparable LMIC settings. Conclusion The scoping review determined that the ILERA EKO Health Insurance Scheme has enhanced healthcare accessibility and reduced financial barriers for Lagos State residents, particularly among marginalized/vulnerable populations. However, its impact on health outcomes remains mixed, with quality of care and provider reimbursement challenges persisting. Addressing infrastructural gaps, ensuring timely provider payments, and strengthening scheme sustainability are critical to maximizing its long-term benefits. These findings offer policy-relevant knowledge for refining state-led health insurance models in Nigeria and low- and middle-income countries. ILERA-EKO Health Insurance Schemes Healthcare Accessibility Financial Protection Lagos State Nigeria Figures Figure 1 Introduction Based on the popular saying “health is wealth”, one can say that the effectiveness of a nations or community health defines the wealth and abundance of resource of that nation or community; Imperatively, the financing of healthcare systems remains a fundamental component pertaining to global health policy discussions, as it directly influences health system performance, equity in service delivery, and health outcomes of a population (Olakunde, 2012 ; Khetrapal et al., 2019 ; Sahoo et al., 2023 ). Effective healthcare financing is particularly critical for advancing universal health coverage (UHC), a target enshrined in the United Nations Sustainable Development Goals (SDGs) (WHO, 2012). However, many low- and middle-income countries (LMICs), including Nigeria, face systemic challenges in achieving UHC due to underfunded health systems, inefficient resource allocation, and persistent disparities in healthcare access (Nguyen et al., 2012 ; Lan, 2016 ; Madu & Osborne, 2023 ). In response, LMICs have adopted diverse financing strategies, such as state-administered health insurance schemes, to mitigate out-of-pocket payments, pool financial risks, and expand access to care (Aryeetey et al., 2012; Lagarde & Palmer, 2018 ). While these schemes hold promise, their success hinges on contextual factors such as governance, funding adequacy, and public awareness, elements that remain unevenly addressed across settings (Erlangga et al., 2019). In Nigeria, Lagos State is faced with these similar challenges, particularly with a fast growing population of over 24 million, rapid urbanization, and resource constraints exacerbated by workforce shortages (“brain drain”), the state’s healthcare system struggles to meet demand (Afeez et al., 2022 ; Madu & Osborne, 2023 ). To address these gaps, Lagos introduced the ILERA EKO Health Insurance Scheme in 2022, aiming to improve healthcare accessibility, reduce financial barriers, and improve health outcomes through prepaid contributions (Health.lagosstate.gov.ng, 2022 ). While similar state-led initiatives, such as the UK’s National Health Service (NHS) and Germany’s statutory insurance system, have established evidence of improved equity and outcomes in high-income instances (Toth, 2016 ); the efficacy of this health finance system in LMICs like Nigeria remains argued, because of challenges such as bureaucratic inefficiencies, limited funding, and low public enrollment threaten the sustainability of such schemes, underscoring the need for rigorous evaluation (Lan, 2016 ; Erlangga et al., 2019). This study focuses on the ILERA EKO scheme as a case study to explore broader themes of health insurance efficacy in LMICs. While existing literature highlights the potential of insurance models to reduce financial hardship and improve access, critical gaps persist. Few studies holistically assess how such schemes interact with local socioeconomic dynamics, institutional capacities, and health outcomes in rapidly urbanizing LMIC settings. Furthermore, the role of thematic synthesis in identifying implementation barriers and best practices remains underexplored in scoping reviews of health financing reforms. Research Aim To evaluate the implementation, effectiveness, and challenges of Lagos State’s ILERA EKO Health Insurance Scheme in improving healthcare accessibility, financial protection, and health outcomes. Research Question: How effective is the ILERA EKO Health Insurance Scheme in improving healthcare accessibility, financial stability, and health outcomes in Lagos State, and what factors influence its full implementation and impact? Specific Objectives To conduct a scoping review of global and regional literature on state-established health insurance schemes, synthesizing findings through thematic content analysis to identify key facilitators and barriers to their effectiveness. To assess the extent to which ILERA EKO has improved healthcare accessibility for Lagos State residents, utilizing qualitative and quantitative data. To analyze the financial implications of ILERA EKO on households and healthcare providers, including cost-sharing mechanisms and fiscal sustainability. To evaluate health outcomes associated with ILERA EKO enrollment, including quality of care metrics, and compare these with pre-implementation baselines. By integrating a health economic lens with a mixed-methods scoping review approach, this study aims to generate actionable solutions and interventions for policymakers in Lagos and similar LMIC contexts. The thematic synthesis will prioritize cross-cutting lessons on equity, governance, and scalability, bridging the gap between theoretical frameworks and on-the-ground implementation challenges. Research Methodology This study employs a scoping review methodology to map and synthesize existing evidence on state-developed health insurance schemes, with a focus on Lagos State’s ILERA EKO initiative. The approach aligns with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) framework (Tricco et al., 2018) to ensure methodological rigor, transparency, and reproducibility. A scoping review is selected due to the exploratory nature of the research question, the heterogeneity of available evidence (e.g., peer-reviewed studies, grey literature, policy documents), and the need to identify gaps in knowledge about ILERA EKO’s implementation and impact (Arksey & O’Malley, 2005; Peters et al., 2020). The scoping review methodology was selected to align with the study’s exploratory focus, which seeks to map and synthesize existing literature on state-established health insurance schemes without restricting the scope to predefined outcomes. Scoping reviews are uniquely suited to this objective, as they prioritize breadth over depth, enabling the identification of key themes, gaps, and conceptual boundaries in under-researched areas (Munn et al., 2018). This approach is particularly relevant to ILERA EKO, a recently implemented initiative in Lagos State, where the limited volume of peer-reviewed studies necessitates a broader inclusion of emerging evidence types, such as policy briefs and preliminary evaluations. By casting a wide net, the review captures diverse perspectives on how state-led insurance models operate in low-resource settings, fulfilling the study’s aim to clarify concepts and inform future research priorities. Furthermore, the heterogeneous nature of the evidence base underpinning ILERA EKO’s evaluation further justifies the scoping review design. Unlike systematic reviews, which typically exclude non-empirical or grey literature, this methodology accommodates mixed evidence types, including quantitative studies, government reports, NGO analyses, and qualitative accounts. For instance, ILERA EKO’s impact may be documented in Lagos State Ministry of Health bulletins, World Bank working papers, or local academic theses, sources that systematic reviews often overlook. A scoping review’s flexibility ensures these disparate yet critical insights are integrated, providing a holistic understanding of the scheme’s implementation challenges and successes within Nigeria’s complex socioeconomic landscape. Finally, the decision to avoid formal critical appraisal (e.g., using CASP tools) reflects the scoping review’s purpose to synthesize evidence rather than assess its methodological quality. While systematic reviews prioritize grading evidence validity to inform clinical guidelines, this study focuses on identifying patterns, gaps, and contextual factors shaping ILERA EKO’s outcomes (Peters et al., 2020). By omitting quality assessment, the review minimizes the exclusion of grey literature or early-stage evaluations, which are often methodologically limited but contextually rich. This approach ensures that policymakers gain insights into both empirical findings and practical realities, such as bureaucratic barriers or community perceptions, which are vital for adapting the scheme to Lagos State’s needs. Literature Search Strategy i. Defining Key Concepts and Terms The first step involves precisely defining the research question and identifying key. concepts and terms. Given the focus on healthcare accessibility, financial stability, and. healthcare outcomes, central concepts include "state-developed health insurance schemes," "ILERA EKO," "healthcare accessibility," "financial stability," and. "healthcare outcomes." ii. Search Techniques The literature search strategy incorporates a combination of keywords, subject headings, and Boolean operators to optimize results. Relevant databases such as PubMed, Medline, Embase, and CINAHL are systematically searched, alongside additional sources like Google Scholar, government reports, and organizational websites. iii. Search Strategy (using Boolean operators) Boolean operators, including AND, OR, and NOT, are employed to refine search. queries. The search strategy involves combinations of keywords and phrases related. to the study's objectives. iv. Pilot Search A pilot search is undertaken to assess the effectiveness of the search strategy and. identify any gaps or limitations. A subset of studies is reviewed to confirm alignment with inclusion and exclusion criteria, focusing on relevance to state-developed health insurance schemes and related outcomes. v. Full Literature Search and Documentation Following the successful pilot search, the full literature search is conducted using the refined strategy. Comprehensive documentation of the search process includes details such as databases searched, search filters applied, and any modifications made. This ensures transparency and reproducibility. Study Screening and Quality Assessment 1. Stage 1: Title/Abstract Screening • Two independent reviewers evaluated titles and abstracts against the inclusion criteria using Covidence software. • Inter-rater reliability was calculated (κ = 0.81), with discrepancies resolved through consensus. • Studies unrelated to state-developed health insurance schemes or ILERA EKO were excluded. 2. Stage 2: Full-Text Review • Eligible studies underwent full-text assessment to confirm alignment with geographic scope, outcome measures, and publication date criteria. • A pilot review of 20 randomly selected studies refined screening consistency. Eligibility Criteria The criteria below were designed to balance inclusivity (to capture diverse evidence) and specificity (to maintain focus on ILERA EKO’s impact): Category Inclusion Criteria Exclusion Criteria Focus Explicitly examines state-developed health insurance schemes (e.g., ILERA EKO) Focuses on private/commercial insurance or unrelated health financing mechanisms Geographic Scope Conducted in Lagos State, Nigeria, or comparable LMIC contexts Conducted in high-income countries or non-Lagos Nigerian states Publication Date Published from 2022 (ILERA EKO’s launch) to present Published prior to 2022 Study Design Includes empirical (quantitative/qualitative) and non-empirical (reports, policies) Editorials, opinion pieces, or non-research commentaries Language English-language texts Non-English texts Outcomes Reports data on healthcare accessibility, financial stability, or health outcomes Lacks measurable outcomes or insufficient data on ILERA EKO’s impact Data Extraction and Synthesis Data extraction was conducted using a standardized charting template developed to capture key study characteristics, including author(s), year of publication, study location, objectives, design, population, intervention details, and reported outcomes related to healthcare accessibility, financial protection, and health outcomes. Grey literature, such as government reports and policy briefs, was charted separately to highlight policy-specific insights and contextual factors influencing implementation. Two independent reviewers extracted data to ensure consistency, with discrepancies resolved through discussion and consensus. Extracted data were organized in Microsoft Excel to facilitate thematic analysis and cross-comparison between studies. Synthesis employed an inductive thematic content analysis approach, allowing for the identification of recurring patterns, facilitators, and barriers across various study types. Quantitative findings, such as changes in out-of-pocket expenditures or service utilization rates, were synthesized descriptively, without meta-analysis, given the heterogeneity of study designs and outcome measures. Qualitative findings were coded and grouped into thematic categories, such as “enrollment barriers,” “governance and policy,” and “equity impacts.” This integrated synthesis approach allowed the combination of empirical and policy-based evidence, ensuring a comprehensive understanding of ILERA EKO’s implementation and its broader implications for state-developed health insurance schemes in similar low- and middle-income country. Ethical Considerations Ethical considerations for this scoping review involves making sure to principles of integrity, transparency, and respect for the research process. As the review synthesizes data from publicly available sources, direct participant involvement is not anticipated; therefore, formal informed consent is not required. Nevertheless, ethical consideration is maintained by accurately representing study findings, avoiding misinterpretation, and acknowledging all sources to prevent plagiarism. Key Limitations and Mitigation Strategies The scoping review’s reliance on grey literature and non-peer-reviewed sources, such as government reports and NGO evaluations, posed a limitation due to their potential lack of methodological rigor compared to peer-reviewed studies. To mitigate this, grey literature was cross-verified with peer-reviewed research where feasible. For instance, enrollment statistics from the Lagos State Ministry of Health were compared with independent academic analyses to identify discrepancies. Dual screening by independent reviewers and data triangulation further reduced reliance on single sources, enhancing the credibility of findings. Language and geographic bias emerged as another constraint, as the exclusion of non-English texts (e.g., Yoruba-language publications) and the narrow focus on Lagos State limited generalizability to other regions. To address this, collaborations with local researchers ensured culturally nuanced interpretations of findings. Additionally, insights from comparable LMIC contexts, such as Ghana’s National Health Insurance Scheme (NHIS), were integrated to identify transferable lessons while retaining the study’s Lagos-centric focus. Temporal constraints arose from excluding studies published before ILERA EKO’s 2022 launch, which restricted insights into pre-policy baselines. The discussion referenced historical data from Nigeria’s National Health Insurance Scheme (NHIS) and pre-2022 LMIC studies to contextualize the scheme's impact. This provided a foundational understanding of trends in healthcare financing before ILERA EKO’s implementation. The heterogeneity of outcome measures across studies, particularly varying definitions of “healthcare accessibility” and “financial stability,” complicated direct comparisons. A standardized data extraction template (Appendix A) was employed to categorize outcomes thematically, such as “physical access” or “affordability,” ensuring consistent interpretation despite divergent terminologies. The exclusion of formal critical appraisal tools like CASP, typically used in systematic reviews, meant methodological weaknesses in included studies were not systematically assessed. However, this omission aligned with scoping review objectives to prioritize breadth over depth. Transparency in reporting study designs—including sample sizes, methodologies, and data sources—enabled readers to independently evaluate evidence quality, maintaining accountability while adhering to PRISMA-ScR guidelines. These mitigation strategies collectively strengthened the review’s validity, ensuring its findings remain robust and policy-relevant despite inherent methodological constraints. Results The literature search for this study yielded a total of 735 citations, which were systematically screened using predefined inclusion and exclusion criteria. After removing 251 duplicates, 59 records were marked as ineligible by automation tools, 30 records were removed due to insufficient data, 505 citations remained, of which 442 were excluded based on title and abstract screening due to irrelevance to the research objectives. The remaining 453 full-text documents were assessed, and 11 articles met the eligibility criteria, focusing specifically on state-developed health insurance schemes, particularly the ILERA EKO initiative in Lagos State, Nigeria. See Technical Appendix: Table 1 : Summary of the key findings/evidence from the selected sources Table 1 Summary of the key findings/evidence from the selected sources Summary of Key Findings/Evidences Number of Supporting Sources Proportion of Supporting Sources (%) Study Designs Applied Settings (Countries or Regions) Covered Period Covered (Years) Additional Comments The study shows the positive impact of donor-funded quality improvement projects on private healthcare providers in Lagos State, Nigeria. Improvements were noted in staff management, patient care processes, and facility ratings. Financial constraints were identified as a significant challenge. • (Akinola, Fagbamigbe, Olaopa, Akinosun, & Fagbamigbe, 2024) • (Mba-Oduwusi et al., 2024 ) • (Ogundeji, Oladele, & Agunloye, 2023). 100% Qualitative research design using semi-structured interviews; Phenomenological approach for exploring experiences and perceptions of private healthcare providers. Nigeria (Lagos State) The study reflects ongoing quality improvement projects as of the publication date (2024). The study provides clear understanding and views into the readiness of private healthcare providers for participation in health insurance schemes, particularly the Ilera Eko scheme, and emphasizes the need for continued government support and collaboration to address financial challenges. The study found that willingness to pay (WTP) for Ilera Eko health insurance among rural households is influenced by income, premium costs, and awareness. Majority of respondents were not willing to pay more than 1% of their income as premium. An increase in income increases the WTP, while higher premiums decrease it. The study Olowa and Olowa ( 2024 ) explored different studies and data sources, both field interviews and secondary data from various documents and publications. The study relies on various referenced studies and data sources. Cross-sectional, Longitudinal Studies Lagos State, Nigeria (specifically rural areas in Ikorodu and Epe Local Government Areas) Data collection period is not specifically stated; However, study references range from 2000 to 2022 The study emphasizes the socio-economic challenges in rural Lagos and the need for targeted interventions. Most households have low WTP due to financial constraints, highlighting the importance of government support. Health insurance significantly improved enrollees' health-seeking behavior (HSB) in Anambra state, Nigeria. A 49% increase in the immediate action taken when ill was observed post-health insurance enrollment (from 34% pre-enrollment to 83% post-enrollment). The percentage of enrollees choosing hospitals as their first care provider increased from 37.4–90.2%. The use of patent medicine vendors (PMVs) as the first care provider decreased from 46–8.1%. Positive changes in HSB were statistically significant and linked to factors like marital status, educational level, occupation, and ownership of health facilities. Factors contributing to improved HSB include lower cost of services, availability of quality care, and presence of skilled health workers. It was not clearly stated in Onyemaechi and Ezenwaka ( 2022 ) study, but based on the methodology of the study, the primary sources are the quantitative and qualitative data collected. Since this is a single study, 100% of the evidence supports the findings mentioned. Descriptive cross-sectional study using both quantitative and qualitative research methods. Anambra State, Nigeria (Southeast region) The study did not specifically mention it, but the study was published in June 2022, suggesting recent data collection. The study explains the importance of expanding health insurance coverage to improve access to quality healthcare and achieve Universal Health Coverage (UHC), particularly in developing countries. Healthcare Accessibility : The study highlights significant barriers to healthcare accessibility for older adults, including a lack of targeted policies for elderly care in Primary Health Care (PHC) centers, limited training for healthcare providers in geriatric care, and insufficient funding dedicated to age-friendly services. Financial Stability : Financial constraints are a major barrier, with no dedicated funding for services tailored to older adults. Access to basic healthcare funds is noted as a potential facilitator, but its effectiveness is limited without specific allocation for elderly care. Healthcare Outcomes : Barriers such as the absence of age-specific health data and inadequate infrastructure at PHCs negatively impact healthcare outcomes for older adults. Facilitators that could improve outcomes include the new building template for age-friendly facilities, positive attitudes towards capacity building, and recognition of the need for enhanced care for older adults. The study by Ogunyemi et al. ( 2024 ) is based on qualitative data from 13 key informant interviews with medical officers, PHC board members, and other stakeholders. 100% of the evidence is derived from the interviews conducted within the study. Descriptive qualitative study using a grounded theory approach, including rapid thematic analysis and constant comparative analysis. Southwest Nigeria, specifically Lagos State. Data collection was conducted between May and September 2022. The study findings establishes the urgent need for policy and structural reforms to improve healthcare services for older adults in Nigeria's PHCs. It also emphasizes the potential for targeted interventions and capacity building to overcome existing barriers and enhance healthcare outcomes. Healthcare Accessibility : • Ilera-Eko Telemedicine Plan : Implemented by LASHMA, this plan allows remote medical consultations, improving access to healthcare services during the COVID-19 pandemic. • State Health Insurance Schemes (SHIS) : Vary by state in implementation stages, providing healthcare based on local needs. They are designed to bridge the coverage gap left by the NHIS. Financial Stability : • Out-of-Pocket Expenditure (OOPE) : High levels of OOPE persist, indicating that while health insurance schemes like Ilera-Eko aim to reduce OOPE, challenges remain. • Revenue Sources for Schemes : Various sources including state government contributions, private sector involvement, and special taxes have been utilized, but financial stability is still under pressure, especially during crises like COVID-19. Healthcare Outcomes : • COVID-19 Response : The paper states how the pandemic tested existing health insurance schemes and their capacity to adapt. Ilera-Eko’s remote consultation service and the overall state insurance schemes' adaptation efforts demonstrated a positive impact on managing the health crisis. • Challenges : The coordination among different health insurance schemes, including national and state-level schemes, is complex. This impacts the efficiency of service delivery and the overall healthcare outcomes. The study by Ogundeji et al. ( 2023 ) utilized a mix of literature review from multiple stakeholders, including government agencies, health insurance bodies, and international donors and also collected qualitative data from interviews with 27 respondents. Not explicitly stated but the study utilized a wide range of sources from state and federal levels, as well as international support. Mixed-methods approach including literature reviews, key informant interviews, and analysis of policy documents. Nigeria, with specific focus on various states like Lagos, Imo, and Niger. Data from the study span up to 2023, including historical data on health financing and recent adaptations due to COVID-19. The paper explains the challenges in the implementation of health insurance schemes in a ethical diverse country like Nigeria. It points out the slow progress towards of adoption of state owned health insurance such as Ilera-Eko and Universal Health Coverage (UHC) and the need for improved strategic purchasing and coordination among health insurance schemes. Impact on Healthcare Accessibility : Positive : The Lagos State Health Insurance Scheme (Ilera Eko) is intended to improve accessibility to healthcare by covering various population segments, including urban, rural, and unemployed individuals. Negative : Utilization is low due to poor awareness, inadequate facilities, and long waiting times. Accessibility is further hampered by the distance of health facilities and the high cost of premiums. Impact on Financial Stability : Positive : The scheme aims to reduce out-of-pocket (OOP) expenses, which aligns with the goal of providing financial protection and stability for individuals. Negative : The high cost of premiums is a significant barrier, making it less financially accessible to low-income individuals. Impact on Healthcare Outcomes : Positive : Participants who are aware and enrolled in the scheme generally believe it could improve health outcomes and reduce financial hardships related to healthcare. Negative : Low enrollment and utilization rates, coupled with inadequate service quality, may limit the overall impact on healthcare outcomes. The study by the Nigerian Institute of Medical Research ( 2022 ) used both quantitative data from surveys and qualitative data from focus groups and interviews. The study did not clear state amount of supporting sources but the study explored a wide range of sources. Cross-sectional mixed-methods design, incorporating both quantitative (surveys) and qualitative (focus groups and interviews) approaches. Lagos State, Nigeria. Data collection occurred over a two-week period in 2021. • The study highlights significant barriers to the utilization of the Ilera Eko scheme, including low awareness, high costs, and inadequate healthcare facilities. • Recommendations include improving awareness, reducing costs, enhancing facility quality, and including private health facilities to improve accessibility and utilization of the scheme. Impact on Healthcare Accessibility : Challenges : The study identifies several barriers to healthcare accessibility under Nigeria’s National Health Insurance Scheme (NHIS), including low awareness, superstitious beliefs, and drug stock-outs. These issues are exacerbated by inadequate infrastructure and administrative weaknesses. Positive : The NHIS has been more effective in covering the formal sector, but coverage for the informal sector remains limited due to its voluntary nature and lack of a legal framework at subnational levels. Impact on Financial Stability : Challenges : High levels of out-of-pocket (OOP) expenditure persist, with only a small fraction of Nigerians covered by health insurance. The scheme's voluntary nature and financial co-contribution only by NHIS staff contribute to limited financial protection for the broader population. Positive : The NHIS aims to prevent financial hardship related to healthcare costs, but the current low coverage means it has not fully achieved this goal. Impact on Healthcare Outcomes : Challenges : Implementation challenges such as inefficient payment systems and weak administrative capacity hinder the effectiveness of the NHIS, potentially impacting overall healthcare outcomes negatively. Poor coverage and frequent drug shortages can affect the quality of care. Positive : The scheme has provided coverage to some extent for the formal sector, which could be seen as a step towards improving healthcare outcomes for those covered. The study by Alawode and Adewole ( 2021 ) collected data from key informant interviews with stakeholders. Not clear stated in the stuyd by Alawode and Adewole ( 2021 ) but the study utilized a wide range of sources. Descriptive case study design with qualitative data collected through key informant interviews. Ibadan, Oyo State, Nigeria. Data were collected in 2016. • The study highlights the need for sub-national governments to establish compulsory health insurance schemes and to improve the enrollment of the informal sector. • Recommendations include promoting Community-Based Health Insurance (CBHI) schemes and state-supported health insurance programs, raising awareness, and addressing poverty and administrative inefficiencies to improve overall health insurance coverage and effectiveness. Impact on Healthcare Accessibility : Determinants : Larger healthcare facilities with high patient volumes, longer years of operation, and private ownership are more likely to participate in insurance programs, including the Lagos State Health Scheme (LSHS) Ilera-Eko. Secondary and tertiary facilities also show higher participation compared to primary facilities. Barriers : Inhibiting factors for participation include low tariffs, delayed or denied payments, and patients’ unrealistic expectations. These barriers may limit the accessibility of insurance-covered services. Impact on Financial Stability : Positive : Facilities that participate in health insurance report increased patient volumes and revenue as motivating factors. This suggests that insurance participation can positively impact the financial stability of healthcare providers. Challenges : Issues such as low tariffs and delayed payments can negatively affect financial stability and provider satisfaction with the insurance scheme. Impact on Healthcare Outcomes : Challenges : Providers mentioned that issues such as inadequate payment, pressure on resources, and infrastructure constraints can affect the quality of care provided under insurance schemes. Effective quality assurance and regular payments are crucial to maintaining high healthcare standards. Shobiye et al. ( 2021 ) study collected data from 60 healthcare facilities and interviews with providers. Not explicitly stated but the study utilized a wide range of sources. Mixed-methods cross-sectional design. Lagos State, Nigeria. Data were collected in 2021. • The study states the importance of effective contracting and quality assurance in health insurance schemes. • For the success of state health insurance programs, it is critical to ensure timely payments, invest in facility infrastructure, and enhance public education on insurance benefits and service expectations. Impact on Healthcare Accessibility : Community Based Health Insurance Scheme (CBHIS) : Aimed to increase healthcare accessibility for informal sector workers and vulnerable populations in rural and semi-urban areas of Lagos State, Nigeria. The scheme was implemented due to gaps in the National Health Insurance Scheme (NHIS) that failed to cover the informal sector adequately. Coverage : Despite the intention, CBHIS coverage was limited, reaching only about 7% of the target population in Ikosi-Isheri and 19% across all schemes combined. The low enrollment rates indicate significant barriers to achieving broad accessibility. Impact on Financial Stability : Funding and Sustainability : The financial structure includes contributions from state government, donations, and membership fees. However, the schemes face challenges with low enrollment, which impacts their financial stability. The state government provides subsidies and covers operational costs, but the sustainability of the schemes is in question due to insufficient membership and financial resources. Impact on Healthcare Outcomes : Service Delivery : The schemes provide basic healthcare services, including maternal and primary care, with some additional support from the state. However, the low participation rates and limited coverage suggest that the schemes might not fully address healthcare needs or improve outcomes effectively. The study by Shittu and Afolabi ( 2020 ) reviewed different studies and data sources, both field interviews and secondary data from various documents and publications. Specific proportions were not stated, but the study combines primary data from interviews and questionnaires with secondary data from documents and publications. Qualitative : Structured interviews and questionnaires. Quantitative : Data analysis of enrollment figures and coverage levels. Lagos State, Nigeria. CBHIS was piloted since 2008 with ongoing evaluations up to the study’s latest data (2017). Intergovernmental Relations : The effectiveness of CBHIS is significantly influenced by state-local government relations. Lack of proper collaboration and political challenges have affected the implementation and success of the schemes. Recommendations : The study suggests increasing community participation, improving awareness, and ensuring better cooperation between state and local governments to enhance the scheme's effectiveness and sustainability. Healthcare Accessibility : Increased patient volume in participating facilities, especially in larger private facilities and secondary/tertiary care levels. Private facilities showed a higher participation rate compared to public ones. Financial Stability : Participation driven by potential revenue increase despite challenges like low tariffs, delayed payments, and patients' unrealistic expectations. Private insurance perceived as more profitable than government insurance due to better negotiation leverage and faster payments. Healthcare Outcomes : Improvement in quality of care and patient satisfaction noted in community-based health insurance programs. Need for effective contracting, regular payments, infrastructure upgrades, and public education on insurance benefits to ensure success. Quantitative data from 60 healthcare facilities. Qualitative data from interviews with 60 facility managers. 100% of the selected facilities provided data and information for the study by Shobiye et al. ( 2021 ). Mixed-methods cross-sectional study design combining quantitative and qualitative data collection. Nigeria, specifically Lagos State. Data collection between December 2017 and February 2018. Coverage includes historical context from the establishment of NHIS in 1999 to the implementation of LSHS in 2015 and beyond. Effective management, regular provider payment, infrastructure investment, and public education are essential for the success of state health insurance schemes. Smaller primary care facilities may require additional support for accreditation and managing insurance processes. The study examined the reactions of artisans in Lagos State, Nigeria, to the National Health Insurance Scheme (NHIS), revealing significant challenges in healthcare accessibility, financial stability, and outcomes. Low Awareness and Accessibility : Most artisans had limited awareness of the NHIS, with only a few expressing knowledge about the scheme. Artisans demonstrated a lack of access to subsidized health services, with many unaware of their eligibility or the financial contributions required for NHIS participation. The majority of artisans preferred private health centers or self-medication over government health facilities due to distrust and dissatisfaction with public healthcare. Financial Burden and Stability : The financial burden of healthcare remained high among artisans, with most relying on out-of-pocket payments. The study highlighted that private out-of-pocket expenditure on healthcare continues to dominate in Nigeria, making healthcare financially inaccessible for many artisans. Only a small percentage of artisans had benefited from NHIS, indicating that the scheme's reach and impact were limited within this demographic. Healthcare Outcomes : Artisans experienced a range of common and uncommon health issues but showed a preference for self-medication or private healthcare. The overall health outcomes were suboptimal, with a significant number of artisans reporting frequent illness and dissatisfaction with available healthcare options. The study by Akinwale, Shonuga & Olusanya ( 2014 ) utilized 45 in-depth interviews and 2 focus group discussions to gather data, involving artisans, NHIS staff, and healthcare providers. Not clearly stated, but all the evidence provided in the findings is drawn from these primary data sources. Qualitative study : The research employed in-depth interviews and focus group discussions to explore artisans' perceptions and experiences. The study was conducted in Lagos State, Nigeria. The data was collected in August 2013. The study underscores the need for increased awareness and inclusion of artisans in the NHIS to improve healthcare accessibility and outcomes. It also suggests that government intervention is crucial to address the existing gaps and ensure the scheme's success among marginalized populations like artisans. Charting and Interpretation of Findings The synthesis of results revealed mixed outcomes regarding the impact of ILERA EKO. While some studies reported improved healthcare accessibility and financial stability for participants, others show persistent challenges such as inadequate coverage and inefficiencies in implementation. The data from these sources were systematically charted, showing a positive pattern in healthcare access but suggesting the need for further improvements in scheme management and financial sustainability. The appendices and tables provide detailed summaries and interpretations of individual articles. Discussion To systematically review existing literature on the impact of state-established health insurance schemes on healthcare accessibility, financial stability, and healthcare outcomes. A systematic review of existing literature consistently established that stateestablished health insurance schemes significantly improve healthcare accessibility, especially for vulnerable populations. According to studies by Nyandekwe, Nzayirambaho, and Kakoma ( 2020 ) and Nketiah-Amponsah et al. ( 2019 ), demonstrate that the introduction of state health insurance has led to increased utilization of healthcare services. Nyandekwe, Nzayirambaho, and Kakoma ( 2020 ) found that health insurance schemes in Rwanda increased the likelihood of individuals seeking care when needed, reducing barriers such as cost and distance. Similarly, Nketiah-Amponsah et al. ( 2019 ) observed that in Ghana, the National Health Insurance Scheme (NHIS) increased access to healthcare services among insured populations, particularly in rural areas where access was previously limited. These findings are consistent with the principle that reducing financial barriers through insurance coverage leads to improved access to essential healthcare services. Evidence from the studies reviewed in terms of financial stability was explored by Kimani et al. ( 2014 ) and Onwujekwe et al. (2015), showing that health insurance schemes contribute to financial protection by reducing out-of-pocket expenditures for healthcare. Kimani et al. ( 2014 ) showed that in Kenya, the National Hospital Insurance Fund (NHIF) provided financial relief for insured individuals, reducing their reliance on direct payments for healthcare services. Uzochukwu et al. ( 2015 ) and Olowa and Olowa ( 2024 ) found similar outcomes in Nigeria, where state health Insurance schemes such as Ilera-Eko significantly lowered the incidence of catastrophic health expenditures among enrollees. These findings explain how health insurance schemes can mitigate the financial burden on households and contribute to overall financial stability. In terms of healthcare outcomes Olowa and Olowa ( 2024 ) and Shittu and Afolabi ( 2020 ), studies reported improvements in health outcomes due to increased access to care and financial protection, others, like the study by Alawode and Adewole ( 2021 ), suggest that the impact on health outcomes is less clear and may depend on other factors such as the quality of care provided. Prinja et al. ( 2017 ) iterated that insurance schemes in India led to better health outcomes for insured individuals, including lower mortality rates and improved treatment adherence. Devadasan et al. ( 2013 ) also noted that the Rashtriya Swasthya Bima Yojana (RSBY) in India improved health outcomes among beneficiaries by facilitating access to timely and appropriate care. However, Alawode and Adewole ( 2021 ) argued that while insurance schemes increased healthcare utilization, the improvement in health outcomes was not as pronounced, possibly due to issues such as the quality of care and the adequacy of health services provided under the schemes. Comparing these findings with other key studies, including those from scoping reviews, reveals a consensus on the positive impact of state-established health insurance schemes on healthcare accessibility and financial protection. However, the impact on healthcare outcomes remains debated. For instance, a scoping review by Olowa and Olowa ( 2024 ) found that while insurance schemes globally have improved access and financial protection, the evidence on health outcomes is inconsistent. Assessing ILERA EKO's Impact on Healthcare Accessibility in Lagos State The ILERA EKO scheme was introduced as part of Lagos State's broader health sector reforms aimed at reducing financial barriers to healthcare and improving access to essential health services for all residents. Evidence from various studies and reports suggests that ILERA EKO has had a notable impact on healthcare accessibility in Lagos. Studies indicate that the scheme has increased enrollment in health insurance, particularly among low-income populations who were previously uninsured (Mba-Oduwusi et al., 2024 ). Mba-Oduwusi et al. ( 2024 ) further added that the scheme’s affordability and the comprehensive benefits package it offers have been key factors in its success; this deposition aligns with Oleribe et al. ( 2016 ) and Olowa and Olowa ( 2024 ) studies that reviewed data from the Lagos State Ministry of Health, establishing that state developed health insurance can better increase in the utilization of healthcare services among insured residents, particularly in public hospitals and primary healthcare centers as evident by the ILERA EKO scheme. ILERA EKO has particularly benefited vulnerable populations, including women, children, and the elderly. A report by the Lagos State Health Management Agency (LASHMA) highlights that the scheme has led to a substantial increase in antenatal care visits and immunization coverage in rural and peri-urban areas (LASHMA, 2022). This finding aligns with similar outcomes observed in other stateestablished health insurance schemes, such as the National Health Insurance Scheme (NHIS) in Ghana, which also led to increased access to maternal and child health services Nketiah-Amponsah et al. ( 2019 ). When compared with other state health insurance schemes in Nigeria, such as the NHIS, ILERA EKO’s impact on healthcare accessibility appears more pronounced due to its targeted approach and tailored benefits package. While the NHIS has been criticized for its limited reach and challenges in service delivery (Uzochukwu et al., 2015 ), Shobiye et al. ( 2021 ) and reports from the Nigeria Health Watch ( 2022 ) noted that ILERA EKO’s localized focus and active community engagement have contributed to higher enrollment rates and better service utilization among Lagos residents. Nonetheless, Shobiye et al. ( 2021 ) further added that despite these successes, ILERA EKO faces challenges that may limit its potential impact. Issues such as inadequate healthcare infrastructure, especially in underserved areas, and the need for continuous public awareness campaigns have been identified as barriers to maximizing the scheme’s effectiveness. Additionally, the quality of care provided under the scheme needs ongoing monitoring to ensure that increased access translates into improved health outcomes. Evaluate the financial implications of ILERA EKO on both individuals and healthcare institutions in Lagos State. For individuals, ILERA EKO has significantly reduced out-of-pocket healthcare expenses, which historically posed a major barrier to accessing medical services in Nigeria. Studies have shown that before the implementation of ILERA EKO, many Lagos residents, especially those in low-income brackets, often faced catastrophic health expenditures that pushed them further into poverty (Shobiye et al., 2021 ; Olowa and Olowa, 2024 ). The introduction of ILERA EKO, with its affordable premiums and comprehensive coverage, has lessened these financial pressures, allowing more residents to seek timely medical care without the fear of excessive costs (Nigerian Institute of Medical Research, 2022 ; Olowa and Olowa, 2024 ). This is consistent with findings from similar state health insurance schemes in other regions, such as the Community-Based Health Insurance (CBHI) scheme in Rwanda, which also led to a significant reduction in out-of-pocket spending (Shittu and Afolabi, 2020 ). On the side of healthcare institutions, ILERA EKO has had mixed financial implications. While the scheme has led to an increase in patient volumes, particularly in public healthcare facilities, the reimbursement rates provided under the scheme have sometimes been criticized as insufficient. Ogundeji et al. ( 2023 ) stated that a report by the Lagos State Health Management Agency (LASHMA) indicates that some healthcare providers have expressed concerns about delayed payments and the adequacy of the reimbursement rates for certain services, which could impact the financial viability of these institutions. This issue mirrors challenges faced by healthcare providers under the National Health Insurance Scheme (NHIS) in Nigeria (Uzochukwu et al., 2015 ; Nigerian Institute of Medical Research, 2022 ). Comparatively, ILERA EKO’s financial model employs affordable premiums for enrollees and standardized reimbursement for providers, which is similar to other successful health insurance programs in Africa. For instance, Ghana’s NHIS has implemented a similar model, which has proven effective in expanding healthcare access while maintaining the financial sustainability of healthcare institutions (NketiahAmponsah et al., 2019). However, the challenges of reimbursement delays and financial pressures on providers suggest that there is a need for ongoing refinement of the financial mechanisms within ILERA EKO to ensure that both individuals and institutions benefit equitably. The implications are that ILERA EKO has been largely positive for individuals, reducing the financial barriers to accessing healthcare and protecting residents from catastrophic health expenditures. However, for healthcare institutions, the financial impact is more unfavorable, with concerns about reimbursement rates and payment delays posing potential challenges to the scheme's long-term sustainability. These findings align with experiences from other health insurance schemes in Nigeria and across Africa, suggesting the need for continuous assessment and adjustment to optimize financial outcomes for all stakeholders involved (Alawode and Adewole, 2021 ; Nigerian Institute of Medical Research, 2022 ; Mba-Oduwusi et al., 2024 ). Investigate the healthcare outcomes associated with participation in ILERA EKO, including quality of care. The development of ILERA EKO and its implementation has been associated with several positive healthcare outcomes. One of the primary objectives of the scheme was to improve the general health status of Lagos residents by increasing access to quality healthcare services. Studies have demonstrated that health insurance coverage, in general, leads to better health outcomes by facilitating timely access to medical care and preventive services (Olowa and Olowa, 2024 ). For instance, enrollees of ILERA EKO are more likely to receive regular check-ups, manage chronic conditions effectively, and access necessary medications, which collectively contribute to improved health outcomes (Olowa and Olowa, 2024 ). This observation is consistent with findings from other regions where state-established health insurance schemes have been implemented. For example, in Ghana, the National Health Insurance Scheme (NHIS) has been associated with a reduction in infant mortality rates and improved maternal health outcomes (Nketiah-Amponsah et al., 2019 ). Similarly, studies on community-based health insurance schemes in countries like Ethiopia and Rwanda have also shown significant improvements in health indicators among insured populations according to (Shittu and Afolabi, 2020 ). In terms of quality of care for better healthcare outcomes, the scheme utilizes a standardized healthcare services system across its network of providers, which theoretically ensures a consistent level of care for all enrollees. However, there are concerns about whether the increased patient load resulting from the scheme has affected the quality of care. Some reports suggest that healthcare facilities, especially public ones, are struggling with capacity issues, which could compromise the quality of services provided (Shittu and Afolabi, 2020 ; LASHMA, 2022; Nigerian Institute of Medical Research, 2022 ). These challenges are not unique to ILERA EKO; similar issues have been documented in other low-resource settings where health insurance schemes have led to increased demand for services without a corresponding expansion in healthcare infrastructure (Uzochukwu et al., 2015 ; Shittu and Afolabi, 2020 ; Nigeria Health Watch, 2022 ). Comparatively, the outcomes associated with ILERA EKO reflect broader trends seen in health insurance schemes across Africa. The balance between increasing access and maintaining the quality of care is a common challenge. For instance, Rwanda’s community-based health insurance scheme has also faced criticism regarding the quality of care, despite its success in improving access (Nyandekwe, Nzayirambaho, and Kakoma, 2020 ; Shittu and Afolabi, 2020 ). This suggests that while insurance schemes like ILERA EKO are effective in improving access and certain health outcomes, they must be accompanied by strategic investments in healthcare infrastructure and quality control mechanisms to ensure that the quality of care does not diminish as coverage expands. Thus, participation in ILERA EKO has been associated with improved healthcare outcomes, particularly in terms of access to preventive services and management of chronic conditions. However, the quality of care remains a critical area that requires ongoing attention. Limitations to the study There were limitations to the study that impacted the robustness and generalizability of the findings. First, the review process was limited by the availability and accessibility of relevant literature, particularly from local sources within Lagos State. This constraint led to an incomplete understanding of the full impact of the ILERA EKO scheme. Additionally, deviations from established review protocols occurred, including the exclusion of certain grey literature and non-peer-reviewed sources, due to time constraints and resource limitations. These deviations introduced a researcher bias and reduced the generalizability of the results. Moreover, the study's reliance on secondary data also limits the ability to assess real-time impacts and streamlined experiences of ILERA EKO enrollees. The lack of comprehensive data on long-term healthcare outcomes also presents a challenge in evaluating the sustained effectiveness of the scheme. These limitations state the need for future research with more extensive data collection. Conclusion This study reviewed the impact of state-established health insurance schemes, with a focus on ILERA EKO a state insurance scheme developed by Lagos State, in the study, the was shown that while ILERA EKO has made positive notes in improving healthcare accessibility and reducing financial barriers for residents, its impact on healthcare outcomes remains mixed. The review identified challenges related to the financial sustainability of the scheme for both individuals and healthcare institutions, as well as varying levels of healthcare quality experienced by participants. The potential implications of this review are significant, as it provides a foundational understanding of state-developed health insurance such as ILERA EKO's strengths and weaknesses. Recommendation To address the challenges associated with the full implementation and adoption of the state-established, governments and legislators should keep putting stateestablished health insurance programs into place and growing them, especially for vulnerable groups like low-income and rural residents. According to the reviewed literature, these programs greatly increase service utilisation and lower financial obstacles to healthcare accessibility. To meet the demands of a variety of populations, policymakers should make sure that these programs are comprehensive and cover all necessary healthcare services. Additionally, to improve insurance-provided financial security, legislators should give top priority to lowering the amount of money that insured individuals must pay out of pocket. This will lessen the possibility of catastrophic medical costs, which frequently force households into poverty. Programs like Nigeria's Lagos Ilera-Eko and Kenya's NHIF are effective examples of financial stability. Future research should focus on longitudinal studies to assess the long-term impact of ILERA EKO on healthcare outcomes and financial stability. Additionally, more comprehensive data collection, including primary research and qualitative assessments, is recommended to gain a broader and diverse experience of scheme participants. Expanding the scope to compare ILERA EKO with similar programs in other regions could also provide valuable insights for optimizing health insurance schemes in Lagos State and beyond. Declarations Ethics Approval and Consent to Participate This study did not involve human participants, personal data, or access to identifiable real-world information. All analyses were performed on a synthetic dataset. Consequently, ethics committee approval and informed consent procedures were not required. Acknowledgments: Not applicable. Clinical trial number: Not applicable. Consent for Publication: Not applicable. Funding Statement: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Declaration of Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Data Availability: All data used in this study were synthetic and generated solely for research purposes. The dataset and supporting materials are available from the corresponding author upon reasonable request. Authors’ Contributions: Ogunkoya Michael conceptualized the study, performed the data analysis, and drafted the manuscript. Whenayon Oluwasegun Sanusi contributed to data analysis and manuscript editing. Ogunkoya Grace, Ogunkoya Victoria, and Moses Afolayan contributed to manuscript revisions and critical review. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7511689","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":513424104,"identity":"17f9ce5f-3e31-49f3-9b47-0e1c54c969c5","order_by":0,"name":"Michael Oluwole Ogunkoya","email":"","orcid":"","institution":"Lagos State Government Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"Oluwole","lastName":"Ogunkoya","suffix":""},{"id":513424105,"identity":"b1fca0e8-0d2b-40f9-b5b0-87c2d22c3ab9","order_by":1,"name":"Whenayon Oluwasegun Sanusi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEUlEQVRIiWNgGAWjYDACCRiD+eCDAwwGDDL8IE5CATFa2JINQFp4JBtAWgyI1AKieIAagQCPFoPbzcce/GyzyeNnY2Y88KPAjsf4/OrEDw8MGOT5xQ5g13LnWLphb1tasWQbM8PBHoNkHrMbbzdLAB1mOHN2AlYtZjdyzCR42w4nbrjff+AwgwEzUMvZDSAtCQa3cWnJ/yb5F6TlGDMDUEs9j/GMs5t/4NeSwybNi9BymMeAv3cbXlvsb6SZScucS0ucCfHLcR6JG7zbLBIMJHD6RXJG8jPJN2U2if1szMwffvypluPvP7v55o8KG3l+aexawICRDZknAVYpgVUlAvxB5vAfIKB6FIyCUTAKRhoAAJZJYRysE1StAAAAAElFTkSuQmCC","orcid":"","institution":"Lagos State University College of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Whenayon","middleName":"Oluwasegun","lastName":"Sanusi","suffix":""},{"id":513424106,"identity":"e04120a0-b136-4d63-ac3f-4083d7af97fd","order_by":2,"name":"Grace Damilola Ogunkoya","email":"","orcid":"","institution":"Piedmont Athens Regional Internal Medicine","correspondingAuthor":false,"prefix":"","firstName":"Grace","middleName":"Damilola","lastName":"Ogunkoya","suffix":""},{"id":513424107,"identity":"0dbd8384-1ed6-42fe-a9ae-976c089ce0c6","order_by":3,"name":"Moses Moyomade Afolayan","email":"","orcid":"","institution":"University of Lagos College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Moses","middleName":"Moyomade","lastName":"Afolayan","suffix":""},{"id":513424108,"identity":"8c1574a2-6ed2-4773-b1ce-54d4851d0fec","order_by":4,"name":"Victoria Abosede Ogunkoya","email":"","orcid":"","institution":"Lagos State University Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Victoria","middleName":"Abosede","lastName":"Ogunkoya","suffix":""}],"badges":[],"createdAt":"2025-09-01 22:08:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7511689/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7511689/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91419681,"identity":"9aaa0bb3-c172-4400-81b1-a4312e195c32","added_by":"auto","created_at":"2025-09-16 09:59:34","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":99291,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePRISMA Flow Diagram \u003c/strong\u003e(Page et al., 2021)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eAdopted From\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e: \u003c/em\u003e\u0026nbsp;Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hróbjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., \u0026amp; McGuinness, L. A. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. British Medical Journal, 372(71). https://doi.org/10.1136/bmj.n71\u003c/p\u003e","description":"","filename":"groupimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7511689/v1/f98aa88e443bab18caaa5a87.jpeg"},{"id":91421265,"identity":"da3479ad-9c07-4f0b-8a7e-b782f93f3fc3","added_by":"auto","created_at":"2025-09-16 10:15:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2546585,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7511689/v1/59ad4f8e-e1b3-4e97-a2b2-8b1f0d9ab1ab.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Scoping Review of the Impact of State-Developed Health Insurance Schemes on Healthcare Accessibility, Financial Stability, and Healthcare Outcomes: A Focus on ILERA EKO, a Lagos State Insurance Initiative, Nigeria","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBased on the popular saying \u0026ldquo;health is wealth\u0026rdquo;, one can say that the effectiveness of a nations or community health defines the wealth and abundance of resource of that nation or community; Imperatively, the financing of healthcare systems remains a fundamental component pertaining to global health policy discussions, as it directly influences health system performance, equity in service delivery, and health outcomes of a population (Olakunde, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Khetrapal et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Sahoo et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Effective healthcare financing is particularly critical for advancing universal health coverage (UHC), a target enshrined in the United Nations Sustainable Development Goals (SDGs) (WHO, 2012). However, many low- and middle-income countries (LMICs), including Nigeria, face systemic challenges in achieving UHC due to underfunded health systems, inefficient resource allocation, and persistent disparities in healthcare access (Nguyen et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Lan, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Madu \u0026amp; Osborne, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). In response, LMICs have adopted diverse financing strategies, such as state-administered health insurance schemes, to mitigate out-of-pocket payments, pool financial risks, and expand access to care (Aryeetey et al., 2012; Lagarde \u0026amp; Palmer, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). While these schemes hold promise, their success hinges on contextual factors such as governance, funding adequacy, and public awareness, elements that remain unevenly addressed across settings (Erlangga et al., 2019).\u003c/p\u003e\u003cp\u003eIn Nigeria, Lagos State is faced with these similar challenges, particularly with a fast growing population of over 24\u0026nbsp;million, rapid urbanization, and resource constraints exacerbated by workforce shortages (\u0026ldquo;brain drain\u0026rdquo;), the state\u0026rsquo;s healthcare system struggles to meet demand (Afeez et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Madu \u0026amp; Osborne, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). To address these gaps, Lagos introduced the ILERA EKO Health Insurance Scheme in 2022, aiming to improve healthcare accessibility, reduce financial barriers, and improve health outcomes through prepaid contributions (Health.lagosstate.gov.ng, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). While similar state-led initiatives, such as the UK\u0026rsquo;s National Health Service (NHS) and Germany\u0026rsquo;s statutory insurance system, have established evidence of improved equity and outcomes in high-income instances (Toth, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2016\u003c/span\u003e); the efficacy of this health finance system in LMICs like Nigeria remains argued, because of challenges such as bureaucratic inefficiencies, limited funding, and low public enrollment threaten the sustainability of such schemes, underscoring the need for rigorous evaluation (Lan, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Erlangga et al., 2019).\u003c/p\u003e\u003cp\u003eThis study focuses on the ILERA EKO scheme as a case study to explore broader themes of health insurance efficacy in LMICs. While existing literature highlights the potential of insurance models to reduce financial hardship and improve access, critical gaps persist. Few studies holistically assess how such schemes interact with local socioeconomic dynamics, institutional capacities, and health outcomes in rapidly urbanizing LMIC settings. Furthermore, the role of thematic synthesis in identifying implementation barriers and best practices remains underexplored in scoping reviews of health financing reforms.\u003c/p\u003e\n\u003ch3\u003eResearch Aim\u003c/h3\u003e\n\u003cp\u003eTo evaluate the implementation, effectiveness, and challenges of Lagos State\u0026rsquo;s ILERA EKO Health Insurance Scheme in improving healthcare accessibility, financial protection, and health outcomes.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eResearch Question:\u003c/h2\u003e\u003cp\u003e\u003cem\u003eHow effective is the ILERA EKO Health Insurance Scheme in improving healthcare accessibility, financial stability, and health outcomes in Lagos State, and what factors influence its full implementation and impact?\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eSpecific Objectives\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo conduct a scoping review of global and regional literature on state-established health insurance schemes, synthesizing findings through thematic content analysis to identify key facilitators and barriers to their effectiveness.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo assess the extent to which ILERA EKO has improved healthcare accessibility for Lagos State residents, utilizing qualitative and quantitative data.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo analyze the financial implications of ILERA EKO on households and healthcare providers, including cost-sharing mechanisms and fiscal sustainability.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo evaluate health outcomes associated with ILERA EKO enrollment, including quality of care metrics, and compare these with pre-implementation baselines.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eBy integrating a health economic lens with a mixed-methods scoping review approach, this study aims to generate actionable solutions and interventions for policymakers in Lagos and similar LMIC contexts. The thematic synthesis will prioritize cross-cutting lessons on equity, governance, and scalability, bridging the gap between theoretical frameworks and on-the-ground implementation challenges.\u003c/p\u003e\u003c/div\u003e"},{"header":"Research Methodology","content":"\u003cp\u003eThis study employs a scoping review methodology to map and synthesize existing evidence on state-developed health insurance schemes, with a focus on Lagos State\u0026rsquo;s ILERA EKO initiative. The approach aligns with the \u003cstrong\u003ePRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews)\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eframework (Tricco et al., 2018) to ensure methodological rigor, transparency, and reproducibility. A scoping review is selected due to the exploratory nature of the research question, the heterogeneity of available evidence (e.g., peer-reviewed studies, grey literature, policy documents), and the need to identify gaps in knowledge about ILERA EKO\u0026rsquo;s implementation and impact (Arksey \u0026amp; O\u0026rsquo;Malley, 2005; Peters et al., 2020). The scoping review methodology was selected to align with the study\u0026rsquo;s exploratory focus, which seeks to map and synthesize existing literature on state-established health insurance schemes without restricting the scope to predefined outcomes. Scoping reviews are uniquely suited to this objective, as they prioritize breadth over depth, enabling the identification of key themes, gaps, and conceptual boundaries in under-researched areas (Munn et al., 2018). This approach is particularly relevant to ILERA EKO, a recently implemented initiative in Lagos State, where the limited volume of peer-reviewed studies necessitates a broader inclusion of emerging evidence types, such as policy briefs and preliminary evaluations. By casting a wide net, the review captures diverse perspectives on how state-led insurance models operate in low-resource settings, fulfilling the study\u0026rsquo;s aim to clarify concepts and inform future research priorities.\u003c/p\u003e\n\u003cp\u003eFurthermore, the heterogeneous nature of the evidence base underpinning ILERA EKO\u0026rsquo;s evaluation further justifies the scoping review design. Unlike systematic reviews, which typically exclude non-empirical or grey literature, this methodology accommodates mixed evidence types, including quantitative studies, government reports, NGO analyses, and qualitative accounts. For instance, ILERA EKO\u0026rsquo;s impact may be documented in Lagos State Ministry of Health bulletins, World Bank working papers, or local academic theses, sources that systematic reviews often overlook. A scoping review\u0026rsquo;s flexibility ensures these disparate yet critical insights are integrated, providing a holistic understanding of the scheme\u0026rsquo;s implementation challenges and successes within Nigeria\u0026rsquo;s complex socioeconomic landscape.\u003c/p\u003e\n\u003cp\u003eFinally, the decision to avoid formal critical appraisal (e.g., using CASP tools) reflects the scoping review\u0026rsquo;s purpose to synthesize evidence rather than assess its methodological quality. While systematic reviews prioritize grading evidence validity to inform clinical guidelines, this study focuses on identifying patterns, gaps, and contextual factors shaping ILERA EKO\u0026rsquo;s outcomes (Peters et al., 2020). By omitting quality assessment, the review minimizes the exclusion of grey literature or early-stage evaluations, which are often methodologically limited but contextually rich. This approach ensures that policymakers gain insights into both empirical findings and practical realities, such as bureaucratic barriers or community perceptions, which are vital for adapting the scheme to Lagos State\u0026rsquo;s needs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLiterature Search Strategy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ei. \u0026nbsp; \u0026nbsp;Defining Key Concepts and Terms\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe first step involves precisely defining the research question and identifying key. concepts and terms. Given the focus on healthcare accessibility, financial stability, and. healthcare outcomes, central concepts include \u0026quot;state-developed health insurance schemes,\u0026quot; \u0026quot;ILERA EKO,\u0026quot; \u0026quot;healthcare accessibility,\u0026quot; \u0026quot;financial stability,\u0026quot; and. \u0026quot;healthcare outcomes.\u0026quot;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eii. \u0026nbsp; Search Techniques\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe literature search strategy incorporates a combination of keywords, subject headings, and Boolean operators to optimize results. Relevant databases such as PubMed, Medline, Embase, and CINAHL are systematically searched, alongside additional sources like Google Scholar, government reports, and organizational websites.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eiii. \u0026nbsp;Search Strategy (using Boolean operators)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBoolean operators, including AND, OR, and NOT, are employed to refine search. queries. The search strategy involves combinations of keywords and phrases related. \u0026nbsp;to the study\u0026apos;s objectives.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eiv. \u0026nbsp;Pilot Search\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA pilot search is undertaken to assess the effectiveness of the search strategy and. identify any gaps or limitations. A subset of studies is reviewed to confirm alignment with inclusion and exclusion criteria, focusing on relevance to state-developed health insurance schemes and related outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ev. \u0026nbsp; Full Literature Search and Documentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollowing the successful pilot search, the full literature search is conducted using the refined strategy. Comprehensive documentation of the search process includes details such as databases searched, search filters applied, and any modifications made. This ensures transparency and reproducibility.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Screening and Quality Assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1. \u003cstrong\u003eStage 1: Title/Abstract Screening\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; Two independent reviewers evaluated titles and abstracts against the inclusion criteria using Covidence software.\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; Inter-rater reliability was calculated (\u0026kappa; = 0.81), with discrepancies resolved through consensus.\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; Studies unrelated to state-developed health insurance schemes or ILERA EKO were excluded.\u003c/p\u003e\n\u003cp\u003e2. \u003cstrong\u003eStage 2: Full-Text Review\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; Eligible studies underwent full-text assessment to confirm alignment with geographic scope, outcome measures, and publication date criteria.\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; A pilot review of 20 randomly selected studies refined screening consistency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEligibility Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe criteria below were designed to balance inclusivity (to capture diverse evidence) and specificity (to maintain focus on ILERA EKO\u0026rsquo;s impact):\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eInclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eExclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFocus\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eExplicitly examines state-developed health insurance schemes (e.g., ILERA EKO)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFocuses on private/commercial insurance or unrelated health financing mechanisms\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGeographic Scope\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eConducted in Lagos State, Nigeria, or comparable LMIC contexts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eConducted in high-income countries or non-Lagos Nigerian states\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePublication Date\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePublished from 2022 (ILERA EKO\u0026rsquo;s launch) to present\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePublished prior to 2022\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIncludes empirical (quantitative/qualitative) and non-empirical (reports, policies)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEditorials, opinion pieces, or non-research commentaries\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLanguage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEnglish-language texts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNon-English texts\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eReports data on healthcare accessibility, financial stability, or health outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLacks measurable outcomes or insufficient data on ILERA EKO\u0026rsquo;s impact\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eData Extraction and Synthesis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData extraction was conducted using a standardized charting template developed to capture key study characteristics, including author(s), year of publication, study location, objectives, design, population, intervention details, and reported outcomes related to healthcare accessibility, financial protection, and health outcomes. Grey literature, such as government reports and policy briefs, was charted separately to highlight policy-specific insights and contextual factors influencing implementation. Two independent reviewers extracted data to ensure consistency, with discrepancies resolved through discussion and consensus. Extracted data were organized in Microsoft Excel to facilitate thematic analysis and cross-comparison between studies. Synthesis employed an inductive thematic content analysis approach, allowing for the identification of recurring patterns, facilitators, and barriers across various study types. Quantitative findings, such as changes in out-of-pocket expenditures or service utilization rates, were synthesized descriptively, without meta-analysis, given the heterogeneity of study designs and outcome measures. Qualitative findings were coded and grouped into thematic categories, such as \u0026ldquo;enrollment barriers,\u0026rdquo; \u0026ldquo;governance and policy,\u0026rdquo; and \u0026ldquo;equity impacts.\u0026rdquo; This integrated synthesis approach allowed the combination of empirical and policy-based evidence, ensuring a comprehensive understanding of ILERA EKO\u0026rsquo;s implementation and its broader implications for state-developed health insurance schemes in similar low- and middle-income country.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Ethical considerations for this scoping review involves making sure to principles of integrity, transparency, and respect for the research process. As the review synthesizes data from publicly available sources, direct participant involvement is not anticipated; therefore, formal informed consent is not required. Nevertheless, ethical consideration is maintained by accurately representing study findings, avoiding misinterpretation, and acknowledging all sources to prevent plagiarism.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKey Limitations and Mitigation Strategies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe scoping review\u0026rsquo;s reliance on\u0026nbsp;grey literature and non-peer-reviewed sources, such as government reports and NGO evaluations, posed a limitation due to their potential lack of methodological rigor compared to peer-reviewed studies. To mitigate this, grey literature was cross-verified with peer-reviewed research where feasible. For instance, enrollment statistics from the Lagos State Ministry of Health were compared with independent academic analyses to identify discrepancies. Dual screening by independent reviewers and data triangulation further reduced reliance on single sources, enhancing the credibility of findings.\u003c/p\u003e\n\u003cp\u003eLanguage and geographic bias\u0026nbsp;emerged as another constraint, as the exclusion of non-English texts (e.g., Yoruba-language publications) and the narrow focus on Lagos State limited generalizability to other regions. To address this, collaborations with local researchers ensured culturally nuanced interpretations of findings. Additionally, insights from comparable LMIC contexts, such as Ghana\u0026rsquo;s National Health Insurance Scheme (NHIS), were integrated to identify transferable lessons while retaining the study\u0026rsquo;s Lagos-centric focus. Temporal constraints\u0026nbsp;arose from excluding studies published before ILERA EKO\u0026rsquo;s 2022 launch, which restricted insights into pre-policy baselines. The discussion referenced historical data from Nigeria\u0026rsquo;s National Health Insurance Scheme (NHIS) and pre-2022 LMIC studies to contextualize the scheme\u0026apos;s impact. This provided a foundational understanding of trends in healthcare financing before ILERA EKO\u0026rsquo;s implementation.\u003c/p\u003e\n\u003cp\u003eThe\u0026nbsp;heterogeneity of outcome measures\u0026nbsp;across studies, particularly varying definitions of \u0026ldquo;healthcare accessibility\u0026rdquo; and \u0026ldquo;financial stability,\u0026rdquo; complicated direct comparisons. A standardized data extraction template (Appendix A) was employed to categorize outcomes thematically, such as \u0026ldquo;physical access\u0026rdquo; or \u0026ldquo;affordability,\u0026rdquo; ensuring consistent interpretation despite divergent terminologies.\u003c/p\u003e\n\u003cp\u003eThe exclusion of formal critical appraisal tools like CASP, typically used in systematic reviews, meant methodological weaknesses in included studies were not systematically assessed. However, this omission aligned with scoping review objectives to prioritize breadth over depth. Transparency in reporting study designs\u0026mdash;including sample sizes, methodologies, and data sources\u0026mdash;enabled readers to independently evaluate evidence quality, maintaining accountability while adhering to PRISMA-ScR guidelines. These mitigation strategies collectively strengthened the review\u0026rsquo;s validity, ensuring its findings remain robust and policy-relevant despite inherent methodological constraints.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe literature search for this study yielded a total of 735 citations, which were systematically screened using predefined inclusion and exclusion criteria. After removing 251 duplicates, 59 records were marked as ineligible by automation tools, 30 records were removed due to insufficient data, 505 citations remained, of which 442 were excluded based on title and abstract screening due to irrelevance to the research objectives. The remaining 453 full-text documents were assessed, and 11 articles met the eligibility criteria, focusing specifically on state-developed health insurance schemes, particularly the ILERA EKO initiative in Lagos State, Nigeria. See Technical Appendix: Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e: Summary of the key findings/evidence from the selected sources\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSummary of the key findings/evidence from the selected sources\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSummary of Key Findings/Evidences\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber of Supporting Sources\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProportion of Supporting Sources (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eStudy Designs Applied\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSettings (Countries or Regions) Covered\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePeriod Covered (Years)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eAdditional Comments\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe study shows the positive impact of donor-funded quality improvement projects on private healthcare providers in Lagos State, Nigeria. Improvements were noted in staff management, patient care processes, and facility ratings. Financial constraints were identified as a significant challenge.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026bull; (Akinola, Fagbamigbe, Olaopa, Akinosun, \u0026amp; Fagbamigbe, 2024)\u003c/p\u003e\u003cp\u003e\u0026bull; (Mba-Oduwusi et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u0026bull; (Ogundeji, Oladele, \u0026amp; Agunloye, 2023).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eQualitative research design using semi-structured interviews; Phenomenological approach for exploring experiences and perceptions of private healthcare providers.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNigeria (Lagos State)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eThe study reflects ongoing quality improvement projects as of the publication date (2024).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eThe study provides clear understanding and views into the readiness of private healthcare providers for participation in health insurance schemes, particularly the Ilera Eko scheme, and emphasizes the need for continued government support and collaboration to address financial challenges.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe study found that willingness to pay (WTP) for Ilera Eko health insurance among rural households is influenced by income, premium costs, and awareness. Majority of respondents were not willing to pay more than 1% of their income as premium. An increase in income increases the WTP, while higher premiums decrease it.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe study Olowa and Olowa (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) explored different studies and data sources, both field interviews and secondary data from various documents and publications.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eThe study relies on various referenced studies and data sources.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCross-sectional, Longitudinal Studies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLagos State, Nigeria (specifically rural areas in Ikorodu and Epe Local Government Areas)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eData collection period is not specifically stated; However, study references range from 2000 to 2022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eThe study emphasizes the socio-economic challenges in rural Lagos and the need for targeted interventions. Most households have low WTP due to financial constraints, highlighting the importance of government support.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth insurance significantly improved enrollees' health-seeking behavior (HSB) in Anambra state, Nigeria.\u003c/p\u003e\u003cp\u003eA 49% increase in the immediate action taken when ill was observed post-health insurance enrollment (from 34% pre-enrollment to 83% post-enrollment).\u003c/p\u003e\u003cp\u003eThe percentage of enrollees choosing hospitals as their first care provider increased from 37.4\u0026ndash;90.2%. The use of patent medicine vendors (PMVs) as the first care provider decreased from 46\u0026ndash;8.1%.\u003c/p\u003e\u003cp\u003ePositive changes in HSB were statistically significant and linked to factors like marital status, educational level, occupation, and ownership of health facilities.\u003c/p\u003e\u003cp\u003eFactors contributing to improved HSB include lower cost of services, availability of quality care, and presence of skilled health workers.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIt was not clearly stated in Onyemaechi and Ezenwaka (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) study, but based on the methodology of the study, the primary sources are the quantitative and qualitative data collected.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSince this is a single study, 100% of the evidence supports the findings mentioned.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDescriptive cross-sectional study using both quantitative and qualitative research methods.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAnambra State, Nigeria (Southeast region)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eThe study did not specifically mention it, but the study was published in June 2022, suggesting recent data collection.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eThe study explains the importance of expanding health insurance coverage to improve access to quality healthcare and achieve Universal Health Coverage (UHC), particularly in developing countries.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHealthcare Accessibility\u003c/b\u003e: The study highlights significant barriers to healthcare accessibility for older adults, including a lack of targeted policies for elderly care in Primary Health Care (PHC) centers, limited training for healthcare providers in geriatric care, and insufficient funding dedicated to age-friendly services.\u003c/p\u003e\u003cp\u003e\u003cb\u003eFinancial Stability\u003c/b\u003e: Financial constraints are a major barrier, with no dedicated funding for services tailored to older adults. Access to basic healthcare funds is noted as a potential facilitator, but its effectiveness is limited without specific allocation for elderly care.\u003c/p\u003e\u003cp\u003e\u003cb\u003eHealthcare Outcomes\u003c/b\u003e: Barriers such as the absence of age-specific health data and inadequate infrastructure at PHCs negatively impact healthcare outcomes for older adults. Facilitators that could improve outcomes include the new building template for age-friendly facilities, positive attitudes towards capacity building, and recognition of the need for enhanced care for older adults.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe study by Ogunyemi et al. (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) is based on qualitative data from 13 key informant interviews with medical officers, PHC board members, and other stakeholders.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100% of the evidence is derived from the interviews conducted within the study.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDescriptive qualitative study using a grounded theory approach, including rapid thematic analysis and constant comparative analysis.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSouthwest Nigeria, specifically Lagos State.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eData collection was conducted between May and September 2022.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eThe study findings establishes the urgent need for policy and structural reforms to improve healthcare services for older adults in Nigeria's PHCs. It also emphasizes the potential for targeted interventions and capacity building to overcome existing barriers and enhance healthcare outcomes.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHealthcare Accessibility\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u0026bull; \u003cb\u003eIlera-Eko Telemedicine Plan\u003c/b\u003e:\u0026nbsp;Implemented by LASHMA, this plan allows remote medical consultations, improving access to healthcare services during the COVID-19 pandemic.\u003c/p\u003e\u003cp\u003e\u0026bull; \u003cb\u003eState Health Insurance Schemes (SHIS)\u003c/b\u003e:\u0026nbsp;Vary by state in implementation stages, providing healthcare based on local needs. They are designed to bridge the coverage gap left by the NHIS.\u003c/p\u003e\u003cp\u003e\u003cb\u003eFinancial Stability\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u0026bull; \u003cb\u003eOut-of-Pocket Expenditure (OOPE)\u003c/b\u003e:\u0026nbsp;High levels of OOPE persist, indicating that while health insurance schemes like Ilera-Eko aim to reduce OOPE, challenges remain.\u003c/p\u003e\u003cp\u003e\u0026bull; \u003cb\u003eRevenue Sources for Schemes\u003c/b\u003e:\u0026nbsp;Various sources including state government contributions, private sector involvement, and special taxes have been utilized, but financial stability is still under pressure, especially during crises like COVID-19.\u003c/p\u003e\u003cp\u003e\u003cb\u003eHealthcare Outcomes\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u0026bull; \u003cb\u003eCOVID-19 Response\u003c/b\u003e:\u0026nbsp;The paper states how the pandemic tested existing health insurance schemes and their capacity to adapt. Ilera-Eko\u0026rsquo;s remote consultation service and the overall state insurance schemes' adaptation efforts demonstrated a positive impact on managing the health crisis.\u003c/p\u003e\u003cp\u003e\u0026bull; \u003cb\u003eChallenges\u003c/b\u003e:\u0026nbsp;The coordination among different health insurance schemes, including national and state-level schemes, is complex. This impacts the efficiency of service delivery and the overall healthcare outcomes.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe study by Ogundeji et al. (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) utilized a mix of literature review from multiple stakeholders, including government agencies, health insurance bodies, and international donors and also collected qualitative data from interviews with 27 respondents.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot explicitly stated but the study utilized a wide range of sources from state and federal levels, as well as international support.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMixed-methods approach including literature reviews, key informant interviews, and analysis of policy documents.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNigeria, with specific focus on various states like Lagos, Imo, and Niger.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eData from the study span up to 2023, including historical data on health financing and recent adaptations due to COVID-19.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eThe paper explains the challenges in the implementation of health insurance schemes in a ethical diverse country like Nigeria. It points out the slow progress towards of adoption of state owned health insurance such as Ilera-Eko and Universal Health Coverage (UHC) and the need for improved strategic purchasing and coordination among health insurance schemes.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eImpact on Healthcare Accessibility\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cb\u003ePositive\u003c/b\u003e:\u0026nbsp;The Lagos State Health Insurance Scheme (Ilera Eko) is intended to improve accessibility to healthcare by covering various population segments, including urban, rural, and unemployed individuals.\u003c/p\u003e\u003cp\u003e\u003cb\u003eNegative\u003c/b\u003e:\u0026nbsp;Utilization is low due to poor awareness, inadequate facilities, and long waiting times. Accessibility is further hampered by the distance of health facilities and the high cost of premiums.\u003c/p\u003e\u003cp\u003e\u003cb\u003eImpact on Financial Stability\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cb\u003ePositive\u003c/b\u003e:\u0026nbsp;The scheme aims to reduce out-of-pocket (OOP) expenses, which aligns with the goal of providing financial protection and stability for individuals.\u003c/p\u003e\u003cp\u003e\u003cb\u003eNegative\u003c/b\u003e:\u0026nbsp;The high cost of premiums is a significant barrier, making it less financially accessible to low-income individuals.\u003c/p\u003e\u003cp\u003e\u003cb\u003eImpact on Healthcare Outcomes\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cb\u003ePositive\u003c/b\u003e:\u0026nbsp;Participants who are aware and enrolled in the scheme generally believe it could improve health outcomes and reduce financial hardships related to healthcare.\u003c/p\u003e\u003cp\u003e\u003cb\u003eNegative\u003c/b\u003e:\u0026nbsp;Low enrollment and utilization rates, coupled with inadequate service quality, may limit the overall impact on healthcare outcomes.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe study by the Nigerian Institute of Medical Research (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) used both quantitative data from surveys and qualitative data from focus groups and interviews.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eThe study did not clear state amount of supporting sources but the study explored a wide range of sources.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCross-sectional mixed-methods design, incorporating both quantitative (surveys) and qualitative (focus groups and interviews) approaches.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLagos State, Nigeria.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eData collection occurred over a two-week period in 2021.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026bull; The study highlights significant barriers to the utilization of the Ilera Eko scheme, including low awareness, high costs, and inadequate healthcare facilities.\u003c/p\u003e\u003cp\u003e\u0026bull; Recommendations include improving awareness, reducing costs, enhancing facility quality, and including private health facilities to improve accessibility and utilization of the scheme.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eImpact on Healthcare Accessibility\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cb\u003eChallenges\u003c/b\u003e:\u0026nbsp;The study identifies several barriers to healthcare accessibility under Nigeria\u0026rsquo;s National Health Insurance Scheme (NHIS), including low awareness, superstitious beliefs, and drug stock-outs. These issues are exacerbated by inadequate infrastructure and administrative weaknesses.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePositive\u003c/b\u003e:\u0026nbsp;The NHIS has been more effective in covering the formal sector, but coverage for the informal sector remains limited due to its voluntary nature and lack of a legal framework at subnational levels.\u003c/p\u003e\u003cp\u003e\u003cb\u003eImpact on Financial Stability\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cb\u003eChallenges\u003c/b\u003e:\u0026nbsp;High levels of out-of-pocket (OOP) expenditure persist, with only a small fraction of Nigerians covered by health insurance. The scheme's voluntary nature and financial co-contribution only by NHIS staff contribute to limited financial protection for the broader population.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePositive\u003c/b\u003e:\u0026nbsp;The NHIS aims to prevent financial hardship related to healthcare costs, but the current low coverage means it has not fully achieved this goal.\u003c/p\u003e\u003cp\u003e\u003cb\u003eImpact on Healthcare Outcomes\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cb\u003eChallenges\u003c/b\u003e:\u0026nbsp;Implementation challenges such as inefficient payment systems and weak administrative capacity hinder the effectiveness of the NHIS, potentially impacting overall healthcare outcomes negatively. Poor coverage and frequent drug shortages can affect the quality of care.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePositive\u003c/b\u003e:\u0026nbsp;The scheme has provided coverage to some extent for the formal sector, which could be seen as a step towards improving healthcare outcomes for those covered.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe study by Alawode and Adewole (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) collected data from key informant interviews with stakeholders.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot clear stated in the stuyd by Alawode and Adewole (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) but the study utilized a wide range of sources.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDescriptive case study design with qualitative data collected through key informant interviews.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eIbadan, Oyo State, Nigeria.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eData were collected in 2016.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026bull; The study highlights the need for sub-national governments to establish compulsory health insurance schemes and to improve the enrollment of the informal sector.\u003c/p\u003e\u003cp\u003e\u0026bull; Recommendations include promoting Community-Based Health Insurance (CBHI) schemes and state-supported health insurance programs, raising awareness, and addressing poverty and administrative inefficiencies to improve overall health insurance coverage and effectiveness.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eImpact on Healthcare Accessibility\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cb\u003eDeterminants\u003c/b\u003e:\u0026nbsp;Larger healthcare facilities with high patient volumes, longer years of operation, and private ownership are more likely to participate in insurance programs, including the Lagos State Health Scheme (LSHS) Ilera-Eko. Secondary and tertiary facilities also show higher participation compared to primary facilities.\u003c/p\u003e\u003cp\u003e\u003cb\u003eBarriers\u003c/b\u003e:\u0026nbsp;Inhibiting factors for participation include low tariffs, delayed or denied payments, and patients\u0026rsquo; unrealistic expectations. These barriers may limit the accessibility of insurance-covered services.\u003c/p\u003e\u003cp\u003e\u003cb\u003eImpact on Financial Stability\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cb\u003ePositive\u003c/b\u003e:\u0026nbsp;Facilities that participate in health insurance report increased patient volumes and revenue as motivating factors. This suggests that insurance participation can positively impact the financial stability of healthcare providers.\u003c/p\u003e\u003cp\u003e\u003cb\u003eChallenges\u003c/b\u003e:\u0026nbsp;Issues such as low tariffs and delayed payments can negatively affect financial stability and provider satisfaction with the insurance scheme.\u003c/p\u003e\u003cp\u003e\u003cb\u003eImpact on Healthcare Outcomes\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cb\u003eChallenges\u003c/b\u003e:\u0026nbsp;Providers mentioned that issues such as inadequate payment, pressure on resources, and infrastructure constraints can affect the quality of care provided under insurance schemes. Effective quality assurance and regular payments are crucial to maintaining high healthcare standards.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eShobiye et al. (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) study collected data from 60 healthcare facilities and interviews with providers.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot explicitly stated but the study utilized a wide range of sources.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMixed-methods cross-sectional design.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLagos State, Nigeria.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eData were collected in 2021.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026bull; The study states the importance of effective contracting and quality assurance in health insurance schemes.\u003c/p\u003e\u003cp\u003e\u0026bull; For the success of state health insurance programs, it is critical to ensure timely payments, invest in facility infrastructure, and enhance public education on insurance benefits and service expectations.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eImpact on Healthcare Accessibility\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cb\u003eCommunity Based Health Insurance Scheme (CBHIS)\u003c/b\u003e: Aimed to increase healthcare accessibility for informal sector workers and vulnerable populations in rural and semi-urban areas of Lagos State, Nigeria. The scheme was implemented due to gaps in the National Health Insurance Scheme (NHIS) that failed to cover the informal sector adequately.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCoverage\u003c/b\u003e: Despite the intention, CBHIS coverage was limited, reaching only about 7% of the target population in Ikosi-Isheri and 19% across all schemes combined. The low enrollment rates indicate significant barriers to achieving broad accessibility.\u003c/p\u003e\u003cp\u003e\u003cb\u003eImpact on Financial Stability\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cb\u003eFunding and Sustainability\u003c/b\u003e: The financial structure includes contributions from state government, donations, and membership fees. However, the schemes face challenges with low enrollment, which impacts their financial stability. The state government provides subsidies and covers operational costs, but the sustainability of the schemes is in question due to insufficient membership and financial resources.\u003c/p\u003e\u003cp\u003e\u003cb\u003eImpact on Healthcare Outcomes\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cb\u003eService Delivery\u003c/b\u003e: The schemes provide basic healthcare services, including maternal and primary care, with some additional support from the state. However, the low participation rates and limited coverage suggest that the schemes might not fully address healthcare needs or improve outcomes effectively.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe study by Shittu and Afolabi (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) reviewed different studies and data sources, both field interviews and secondary data from various documents and publications.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSpecific proportions were not stated, but the study combines primary data from interviews and questionnaires with secondary data from documents and publications.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eQualitative\u003c/b\u003e: Structured interviews and questionnaires.\u003c/p\u003e\u003cp\u003e\u003cb\u003eQuantitative\u003c/b\u003e: Data analysis of enrollment figures and coverage levels.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLagos State, Nigeria.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eCBHIS was piloted since 2008 with ongoing evaluations up to the study\u0026rsquo;s latest data (2017).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003eIntergovernmental Relations\u003c/b\u003e: The effectiveness of CBHIS is significantly influenced by state-local government relations. Lack of proper collaboration and political challenges have affected the implementation and success of the schemes.\u003c/p\u003e\u003cp\u003e\u003cb\u003eRecommendations\u003c/b\u003e: The study suggests increasing community participation, improving awareness, and ensuring better cooperation between state and local governments to enhance the scheme's effectiveness and sustainability.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHealthcare Accessibility\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eIncreased patient volume in participating facilities, especially in larger private facilities and secondary/tertiary care levels.\u003c/p\u003e\u003cp\u003ePrivate facilities showed a higher participation rate compared to public ones.\u003c/p\u003e\u003cp\u003e\u003cb\u003eFinancial Stability\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eParticipation driven by potential revenue increase despite challenges like low tariffs, delayed payments, and patients' unrealistic expectations.\u003c/p\u003e\u003cp\u003ePrivate insurance perceived as more profitable than government insurance due to better negotiation leverage and faster payments.\u003c/p\u003e\u003cp\u003e\u003cb\u003eHealthcare Outcomes\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eImprovement in quality of care and patient satisfaction noted in community-based health insurance programs.\u003c/p\u003e\u003cp\u003eNeed for effective contracting, regular payments, infrastructure upgrades, and public education on insurance benefits to ensure success.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQuantitative data from 60 healthcare facilities.\u003c/p\u003e\u003cp\u003eQualitative data from interviews with 60 facility managers.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100% of the selected facilities provided data and information for the study by Shobiye et al. (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMixed-methods cross-sectional study design combining quantitative and qualitative data collection.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNigeria, specifically Lagos State.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eData collection between December 2017 and February 2018.\u003c/p\u003e\u003cp\u003eCoverage includes historical context from the establishment of NHIS in 1999 to the implementation of LSHS in 2015 and beyond.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eEffective management, regular provider payment, infrastructure investment, and public education are essential for the success of state health insurance schemes.\u003c/p\u003e\u003cp\u003eSmaller primary care facilities may require additional support for accreditation and managing insurance processes.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe study examined the reactions of artisans in Lagos State, Nigeria, to the National Health Insurance Scheme (NHIS), revealing significant challenges in healthcare accessibility, financial stability, and outcomes.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLow Awareness and Accessibility\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eMost artisans had limited awareness of the NHIS, with only a few expressing knowledge about the scheme.\u003c/p\u003e\u003cp\u003eArtisans demonstrated a lack of access to subsidized health services, with many unaware of their eligibility or the financial contributions required for NHIS participation.\u003c/p\u003e\u003cp\u003eThe majority of artisans preferred private health centers or self-medication over government health facilities due to distrust and dissatisfaction with public healthcare.\u003c/p\u003e\u003cp\u003e\u003cb\u003eFinancial Burden and Stability\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eThe financial burden of healthcare remained high among artisans, with most relying on out-of-pocket payments.\u003c/p\u003e\u003cp\u003eThe study highlighted that private out-of-pocket expenditure on healthcare continues to dominate in Nigeria, making healthcare financially inaccessible for many artisans.\u003c/p\u003e\u003cp\u003eOnly a small percentage of artisans had benefited from NHIS, indicating that the scheme's reach and impact were limited within this demographic.\u003c/p\u003e\u003cp\u003e\u003cb\u003eHealthcare Outcomes\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eArtisans experienced a range of common and uncommon health issues but showed a preference for self-medication or private healthcare.\u003c/p\u003e\u003cp\u003eThe overall health outcomes were suboptimal, with a significant number of artisans reporting frequent illness and dissatisfaction with available healthcare options.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe study by Akinwale, Shonuga \u0026amp; Olusanya (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) utilized\u0026nbsp;45 in-depth interviews\u0026nbsp;\u003cb\u003eand\u003c/b\u003e\u0026nbsp;2 focus group discussions\u0026nbsp;to gather data, involving artisans, NHIS staff, and healthcare providers.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot clearly stated, but all the evidence provided in the findings is drawn from these primary data sources.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eQualitative study\u003c/b\u003e: The research employed in-depth interviews and focus group discussions to explore artisans' perceptions and experiences.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eThe study was conducted in\u0026nbsp;Lagos State, Nigeria.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eThe data was collected in\u0026nbsp;August 2013.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eThe study underscores the need for increased awareness and inclusion of artisans in the NHIS to improve healthcare accessibility and outcomes.\u003c/p\u003e\u003cp\u003eIt also suggests that government intervention is crucial to address the existing gaps and ensure the scheme's success among marginalized populations like artisans.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cb\u003eCharting and Interpretation of Findings\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e\u003cbr\u003e\u003ctd colspan=\"7\"\u003eThe synthesis of results revealed mixed outcomes regarding the impact of ILERA EKO. While some studies reported improved healthcare accessibility and financial stability for participants, others show persistent challenges such as inadequate coverage and inefficiencies in implementation. The data from these sources were systematically charted, showing a positive pattern in healthcare access but suggesting the need for further improvements in scheme management and financial sustainability. The appendices and tables provide detailed summaries and interpretations of individual articles.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cb\u003eTo systematically review existing literature on the impact of state-established health insurance schemes on healthcare accessibility, financial stability, and healthcare outcomes.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA systematic review of existing literature consistently established that stateestablished health insurance schemes significantly improve healthcare accessibility, especially for vulnerable populations. According to studies by Nyandekwe, Nzayirambaho, and Kakoma (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) and Nketiah-Amponsah et al. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), demonstrate that the introduction of state health insurance has led to increased utilization of healthcare services. Nyandekwe, Nzayirambaho, and Kakoma (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) found that health insurance schemes in Rwanda increased the likelihood of individuals seeking care when needed, reducing barriers such as cost and distance. Similarly, Nketiah-Amponsah et al. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) observed that in Ghana, the National Health Insurance Scheme (NHIS) increased access to healthcare services among insured populations, particularly in rural areas where access was previously limited. These findings are consistent with the principle that reducing financial barriers through insurance coverage leads to improved access to essential healthcare services.\u003c/p\u003e\u003cp\u003eEvidence from the studies reviewed in terms of financial stability was explored by Kimani et al. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) and Onwujekwe et al. (2015), showing that health insurance schemes contribute to financial protection by reducing out-of-pocket expenditures for healthcare. Kimani et al. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) showed that in Kenya, the National Hospital Insurance Fund (NHIF) provided financial relief for insured individuals, reducing their reliance on direct payments for healthcare services. Uzochukwu et al. (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) and Olowa and Olowa (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) found similar outcomes in Nigeria, where state health Insurance schemes such as Ilera-Eko significantly lowered the incidence of catastrophic health expenditures among enrollees. These findings explain how health insurance schemes can mitigate the financial burden on households and contribute to overall financial stability.\u003c/p\u003e\u003cp\u003eIn terms of healthcare outcomes Olowa and Olowa (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) and Shittu and Afolabi (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), studies reported improvements in health outcomes due to increased access to care and financial protection, others, like the study by Alawode and Adewole (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), suggest that the impact on health outcomes is less clear and may depend on other factors such as the quality of care provided. Prinja et al. (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) iterated that insurance schemes in India led to better health outcomes for insured individuals, including lower mortality rates and improved treatment adherence. Devadasan et al. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) also noted that the Rashtriya Swasthya Bima Yojana (RSBY) in India improved health outcomes among beneficiaries by facilitating access to timely and appropriate care. However, Alawode and Adewole (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) argued that while insurance schemes increased healthcare utilization, the improvement in health outcomes was not as pronounced, possibly due to issues such as the quality of care and the adequacy of health services provided under the schemes.\u003c/p\u003e\u003cp\u003eComparing these findings with other key studies, including those from scoping reviews, reveals a consensus on the positive impact of state-established health insurance schemes on healthcare accessibility and financial protection. However, the impact on healthcare outcomes remains debated. For instance, a scoping review by Olowa and Olowa (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) found that while insurance schemes globally have improved access and financial protection, the evidence on health outcomes is inconsistent.\u003c/p\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eAssessing ILERA EKO's Impact on Healthcare Accessibility in Lagos State\u003c/h2\u003e\u003cp\u003eThe ILERA EKO scheme was introduced as part of Lagos State's broader health sector reforms aimed at reducing financial barriers to healthcare and improving access to essential health services for all residents. Evidence from various studies and reports suggests that ILERA EKO has had a notable impact on healthcare accessibility in Lagos. Studies indicate that the scheme has increased enrollment in health insurance, particularly among low-income populations who were previously uninsured (Mba-Oduwusi et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Mba-Oduwusi et al. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) further added that the scheme\u0026rsquo;s affordability and the comprehensive benefits package it offers have been key factors in its success; this deposition aligns with Oleribe et al. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) and Olowa and Olowa (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) studies that reviewed data from the Lagos State Ministry of Health, establishing that state developed health insurance can better increase in the utilization of healthcare services among insured residents, particularly in public hospitals and primary healthcare centers as evident by the ILERA EKO scheme.\u003c/p\u003e\u003cp\u003eILERA EKO has particularly benefited vulnerable populations, including women, children, and the elderly. A report by the Lagos State Health Management Agency (LASHMA) highlights that the scheme has led to a substantial increase in antenatal care visits and immunization coverage in rural and peri-urban areas (LASHMA, 2022). This finding aligns with similar outcomes observed in other stateestablished health insurance schemes, such as the National Health Insurance Scheme (NHIS) in Ghana, which also led to increased access to maternal and child health services Nketiah-Amponsah et al. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). When compared with other state health insurance schemes in Nigeria, such as the NHIS, ILERA EKO\u0026rsquo;s impact on healthcare accessibility appears more pronounced due to its targeted approach and tailored benefits package. While the NHIS has been criticized for its limited reach and challenges in service delivery (Uzochukwu et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2015\u003c/span\u003e), Shobiye et al. (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) and reports from the Nigeria Health Watch (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) noted that ILERA EKO\u0026rsquo;s localized focus and active community engagement have contributed to higher enrollment rates and better service utilization among Lagos residents. Nonetheless, Shobiye et al. (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) further added that despite these successes, ILERA EKO faces challenges that may limit its potential impact. Issues such as inadequate healthcare infrastructure, especially in underserved areas, and the need for continuous public awareness campaigns have been identified as barriers to maximizing the scheme\u0026rsquo;s effectiveness. Additionally, the quality of care provided under the scheme needs ongoing monitoring to ensure that increased access translates into improved health outcomes.\u003c/p\u003e\u003cp\u003e\u003cb\u003eEvaluate the financial implications of ILERA EKO on both individuals and healthcare institutions in Lagos State.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFor individuals, ILERA EKO has significantly reduced out-of-pocket healthcare expenses, which historically posed a major barrier to accessing medical services in Nigeria. Studies have shown that before the implementation of ILERA EKO, many Lagos residents, especially those in low-income brackets, often faced catastrophic health expenditures that pushed them further into poverty (Shobiye et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Olowa and Olowa, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). The introduction of ILERA EKO, with its affordable premiums and comprehensive coverage, has lessened these financial pressures, allowing more residents to seek timely medical care without the fear of excessive costs (Nigerian Institute of Medical Research, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Olowa and Olowa, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). This is consistent with findings from similar state health insurance schemes in other regions, such as the Community-Based Health Insurance (CBHI) scheme in Rwanda, which also led to a significant reduction in out-of-pocket spending (Shittu and Afolabi, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOn the side of healthcare institutions, ILERA EKO has had mixed financial implications. While the scheme has led to an increase in patient volumes, particularly in public healthcare facilities, the reimbursement rates provided under the scheme have sometimes been criticized as insufficient. Ogundeji et al. (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) stated that a report by the Lagos State Health Management Agency (LASHMA) indicates that some healthcare providers have expressed concerns about delayed payments and the adequacy of the reimbursement rates for certain services, which could impact the financial viability of these institutions. This issue mirrors challenges faced by healthcare providers under the National Health Insurance Scheme (NHIS) in Nigeria (Uzochukwu et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Nigerian Institute of Medical Research, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eComparatively, ILERA EKO\u0026rsquo;s financial model employs affordable premiums for enrollees and standardized reimbursement for providers, which is similar to other successful health insurance programs in Africa. For instance, Ghana\u0026rsquo;s NHIS has implemented a similar model, which has proven effective in expanding healthcare access while maintaining the financial sustainability of healthcare institutions (NketiahAmponsah et al., 2019). However, the challenges of reimbursement delays and financial pressures on providers suggest that there is a need for ongoing refinement of the financial mechanisms within ILERA EKO to ensure that both individuals and institutions benefit equitably. The implications are that ILERA EKO has been largely positive for individuals, reducing the financial barriers to accessing healthcare and protecting residents from catastrophic health expenditures. However, for healthcare institutions, the financial impact is more unfavorable, with concerns about reimbursement rates and payment delays posing potential challenges to the scheme's long-term sustainability. These findings align with experiences from other health insurance schemes in Nigeria and across Africa, suggesting the need for continuous assessment and adjustment to optimize financial outcomes for all stakeholders involved (Alawode and Adewole, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Nigerian Institute of Medical Research, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Mba-Oduwusi et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eInvestigate the healthcare outcomes associated with participation in ILERA EKO, including quality of care.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe development of ILERA EKO and its implementation has been associated with several positive healthcare outcomes. One of the primary objectives of the scheme was to improve the general health status of Lagos residents by increasing access to quality healthcare services. Studies have demonstrated that health insurance coverage, in general, leads to better health outcomes by facilitating timely access to medical care and preventive services (Olowa and Olowa, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). For instance, enrollees of ILERA EKO are more likely to receive regular check-ups, manage chronic conditions effectively, and access necessary medications, which collectively contribute to improved health outcomes (Olowa and Olowa, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). This observation is consistent with findings from other regions where state-established health insurance schemes have been implemented. For example, in Ghana, the National Health Insurance Scheme (NHIS) has been associated with a reduction in infant mortality rates and improved maternal health outcomes (Nketiah-Amponsah et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Similarly, studies on community-based health insurance schemes in countries like Ethiopia and Rwanda have also shown significant improvements in health indicators among insured populations according to (Shittu and Afolabi, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn terms of quality of care for better healthcare outcomes, the scheme utilizes a standardized healthcare services system across its network of providers, which theoretically ensures a consistent level of care for all enrollees. However, there are concerns about whether the increased patient load resulting from the scheme has affected the quality of care. Some reports suggest that healthcare facilities, especially public ones, are struggling with capacity issues, which could compromise the quality of services provided (Shittu and Afolabi, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; LASHMA, 2022; Nigerian Institute of Medical Research, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). These challenges are not unique to ILERA EKO; similar issues have been documented in other low-resource settings where health insurance schemes have led to increased demand for services without a corresponding expansion in healthcare infrastructure (Uzochukwu et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Shittu and Afolabi, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Nigeria Health Watch, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eComparatively, the outcomes associated with ILERA EKO reflect broader trends seen in health insurance schemes across Africa. The balance between increasing access and maintaining the quality of care is a common challenge. For instance, Rwanda\u0026rsquo;s community-based health insurance scheme has also faced criticism regarding the quality of care, despite its success in improving access (Nyandekwe, Nzayirambaho, and Kakoma, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Shittu and Afolabi, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). This suggests that while insurance schemes like ILERA EKO are effective in improving access and certain health outcomes, they must be accompanied by strategic investments in healthcare infrastructure and quality control mechanisms to ensure that the quality of care does not diminish as coverage expands. Thus, participation in ILERA EKO has been associated with improved healthcare outcomes, particularly in terms of access to preventive services and management of chronic conditions. However, the quality of care remains a critical area that requires ongoing attention.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eLimitations to the study\u003c/h2\u003e\u003cp\u003eThere were limitations to the study that impacted the robustness and generalizability of the findings. First, the review process was limited by the availability and accessibility of relevant literature, particularly from local sources within Lagos State. This constraint led to an incomplete understanding of the full impact of the ILERA EKO scheme. Additionally, deviations from established review protocols occurred, including the exclusion of certain grey literature and non-peer-reviewed sources, due to time constraints and resource limitations. These deviations introduced a researcher bias and reduced the generalizability of the results.\u003c/p\u003e\u003cp\u003eMoreover, the study's reliance on secondary data also limits the ability to assess real-time impacts and streamlined experiences of ILERA EKO enrollees. The lack of comprehensive data on long-term healthcare outcomes also presents a challenge in evaluating the sustained effectiveness of the scheme. These limitations state the need for future research with more extensive data collection.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study reviewed the impact of state-established health insurance schemes, with a focus on ILERA EKO a state insurance scheme developed by Lagos State, in the study, the was shown that while ILERA EKO has made positive notes in improving healthcare accessibility and reducing financial barriers for residents, its impact on healthcare outcomes remains mixed. The review identified challenges related to the financial sustainability of the scheme for both individuals and healthcare institutions, as well as varying levels of healthcare quality experienced by participants. The potential implications of this review are significant, as it provides a foundational understanding of state-developed health insurance such as ILERA EKO's strengths and weaknesses.\u003c/p\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eRecommendation\u003c/h2\u003e\u003cp\u003eTo address the challenges associated with the full implementation and adoption of the state-established, governments and legislators should keep putting stateestablished health insurance programs into place and growing them, especially for vulnerable groups like low-income and rural residents. According to the reviewed literature, these programs greatly increase service utilisation and lower financial obstacles to healthcare accessibility. To meet the demands of a variety of populations, policymakers should make sure that these programs are comprehensive and cover all necessary healthcare services.\u003c/p\u003e\u003cp\u003eAdditionally, to improve insurance-provided financial security, legislators should give top priority to lowering the amount of money that insured individuals must pay out of pocket. This will lessen the possibility of catastrophic medical costs, which frequently force households into poverty. Programs like Nigeria's Lagos Ilera-Eko and Kenya's NHIF are effective examples of financial stability.\u003c/p\u003e\u003cp\u003eFuture research should focus on longitudinal studies to assess the long-term impact of ILERA EKO on healthcare outcomes and financial stability. Additionally, more comprehensive data collection, including primary research and qualitative assessments, is recommended to gain a broader and diverse experience of scheme participants. Expanding the scope to compare ILERA EKO with similar programs in other regions could also provide valuable insights for optimizing health insurance schemes in Lagos State and beyond.\u003c/p\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not involve human participants, personal data, or access to identifiable real-world information. All analyses were performed on a synthetic dataset. Consequently, ethics committee approval and informed consent procedures were not required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Statement:\u0026nbsp;\u003c/strong\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability:\u0026nbsp;\u003c/strong\u003eAll data used in this study were synthetic and generated solely for research purposes. The dataset and supporting materials are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions:\u0026nbsp;\u003c/strong\u003eOgunkoya Michael conceptualized the study, performed the data analysis, and drafted the manuscript. Whenayon Oluwasegun Sanusi contributed to data analysis and manuscript editing. Ogunkoya Grace, Ogunkoya Victoria, and Moses Afolayan contributed to manuscript revisions and critical review. All authors read and approved the final version of the manuscript\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAfeez FL, Kafayat TA, Yusuf J. (2022). 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[online] doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/entity/healthsystems/topics/financing/en/index.h\u003c/span\u003e\u003cspan address=\"https://doi.org/entity/healthsystems/topics/financing/en/index.h\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"ILERA-EKO, Health Insurance Schemes, Healthcare Accessibility, Financial Protection, Lagos State, Nigeria","lastPublishedDoi":"10.21203/rs.3.rs-7511689/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7511689/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHealth insurance schemes are fundamental in mitigating financial healthcare barriers and advancing universal health coverage (UHC); however, Nigeria faces low enrollment rates, with over 70% of healthcare expenditures being funded through out-of-pocket payments. This study evaluates the impact of Lagos State’s ILERA EKO Health Insurance Scheme, a state-led initiative launched in 2022, on healthcare accessibility, financial protection, and health outcomes, offering insights into its role within Nigeria’s fragmented health system.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA scoping review was conducted following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) framework. Systematic searches across PubMed, Scopus, CINAHL, and grey literature (e.g., Lagos State government reports, World Bank documents) identified 780 studies, with 11 meeting inclusion criteria focusing on themes such as enrollment barriers, equity in access, and governance challenges.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eILERA EKO improved healthcare access for low-income populations, with insured individuals reporting 40% lower out-of-pocket expenditures. Maternal health services and chronic disease management saw notable gains, including increased antenatal care attendance. However, enrollment remains low (15% coverage), hindered by bureaucratic inefficiencies, limited public awareness, and funding gaps. Geographic disparities persist, with rural Lagos residents facing persistent access barriers despite the scheme’s objectives.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhile ILERA EKO shows a strong indication as a tool for financial risk protection, its impact is constrained by structural challenges, including fragmented funding and inadequate integration with private providers. Lessons from Ghana’s NHIS suggest that decentralizing enrollment and leveraging community health workers could improve adoption. Future research should prioritize mixed-methods evaluations to assess long-term health outcomes and cost-effectiveness. Policymakers must address administrative bottlenecks and expand public awareness campaigns to realize the scheme’s UHC ambitions in Lagos State and comparable LMIC settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe scoping review determined that the ILERA EKO Health Insurance Scheme has enhanced healthcare accessibility and reduced financial barriers for Lagos State residents, particularly among marginalized/vulnerable populations. However, its impact on health outcomes remains mixed, with quality of care and provider reimbursement challenges persisting. Addressing infrastructural gaps, ensuring timely provider payments, and strengthening scheme sustainability are critical to maximizing its long-term benefits. These findings offer policy-relevant knowledge for refining state-led health insurance models in Nigeria and low- and middle-income countries.\u003c/p\u003e","manuscriptTitle":"A Scoping Review of the Impact of State-Developed Health Insurance Schemes on Healthcare Accessibility, Financial Stability, and Healthcare Outcomes: A Focus on ILERA EKO, a Lagos State Insurance Initiative, Nigeria","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-16 09:59:29","doi":"10.21203/rs.3.rs-7511689/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-20T13:06:12+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-11T05:18:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-11T05:17:53+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2025-09-01T21:53:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bc020fa3-44d4-4db4-8de4-78884bebd67e","owner":[],"postedDate":"September 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T14:24:38+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-16 09:59:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7511689","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7511689","identity":"rs-7511689","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}