Abstract / Summary
Abstract Background Sickle Cell Disease (SCD) leads to major health challenges and significant financial burdens in Sub-Saharan Africa. Government health insurance programs, such as the AbbaCare Equity Fund in Kano State, Nigeria, support vulnerable groups and help move toward Universal Health Coverage (UHC). Still, there is limited evidence about how effective these programs are and how well they are implemented. Methods We conducted a Hybrid type-2 stepped-wedge cluster randomised trial in three accredited health facility clusters in Kano State. Over 24 months, we enrolled 1,200 SCD patients in a 2:1:1 ratio at Murtala Muhammad Specialist Hospital (MMSH), Khalifa Isyaka Rabiu Paediatrics Hospital (KSIPH), and Hasiya Bayero Paediatrics Hospital (HBPH), based on patient attendance. The clusters transitioned sequentially every four months, each cluster moved from standard fee-for-service care to the AbbaCare Initiative, which gave full premium exemption to registered SCD patients. The main clinical outcomes were annual rates of vaso-occlusive crises (VOC) and emergency hospital admissions, analysed with Generalised Linear Mixed Models (GLMM). The main economic outcome was Catastrophic Health Expenditure (CHE), defined as out-of-pocket spending greater than 10% of household income. We used a mixed methods approach and the Consolidated Framework for Implementation Research (CFIR) to assess implementation outcomes. Results Out of the 1,200 SCD patients, those enrolled in AbbaCare saw a 38% drop in annual VOC crises (aRR = 0.62, 95% CI 0.54–0.71, p < 0.001) and a 44% drop in emergency admissions (aRR = 0.56, 95% CI 0.48–0.66, p < 0.001). The percentage of patients with good Hydroxyurea adherence (MPR 80%) rose from 21.4% to 68.2% (p < 0.001). The share of households facing catastrophic health expenses (CHE) fell from 64.8% to 8.3% after joining AbbaCare (aOR = 0.09, 95% CI 0.06–0.14, p < 0.001). Qualitative results showed strong policy support, but challenges like rural facility exclusion and National Identification Number (NIN) requirements limited the program’s reach. Conclusion The AbbaCare Equity Fund was associated with improved clinical outcomes, medication access, and financial protection among people with SCD. Strengthening drug supply chains, expanding rural facility coverage, and simplifying enrolment requirements may facilitate scale-up of equitable social health insurance in resource-constrained settings.