Achieving Universal Health Coverage in Nigeria One State at a Time: A Public-Private Partnership Community-Based Health Insurance Model
The 58th World Health Assembly in 2005 adopted a widely supported resolution encouraging countries to plan a transition to UHC and in 2010, the WHO World Health Report focused on alternative financing initiatives for achieving universal coverage. A key feature of UHC is that it includes prepayment and that it supports risk pooling, which ensures the spread of risk across time and across individuals. A broad range of risk-pooling mechanisms or insurance schemes are increasingly being utilized across the developing world to increase access and reduce the financial burden of health. Two years ago, in a rural community in Kwara State, Nigeria, we met Fatima a 62 year old grandmother who was struggling to care for herself and her two granddaughters aged three and nine. The children had been left with Fatima when their parents went to Lagos to look for work. Shortly thereafter, Fatima became ill, leaving her unable to work selling her homemade soybean cakes in the market for an income. She was forced to borrow money from other family members to pay for her medical expenses. When she could no longer borrow money she had to reduce spending on food items for herself and her grandchildren to buy medicine from the local medicine vendor in her village. Fatima, as the majority of poor Nigerians, was not covered by Nigeria’s National Health Insurance Scheme (NHIS) because she is not formally employed. She was suffering from severe hypertension, both of her granddaughters were malnourished and the youngest was suffering from malaria when a Hygeia Community Health Care (HCHC) enrollment officer arrived in her community a year later. By enrolling in the HCHC health insurance plan supported by the Dutch Health Insurance Fund (HIF) and implemented by PharmAccess, a nongovernmental organization (NGO), Fatima was able to receive the care that she and her granddaughter needed in the clinic, which had already been upgraded through the same program. With the appropriate treatment, her health stabilized and soon she was able to get back to work, earn a livelihood and care for her granddaughters.
Fatima’s story is not uncommon in Nigeria and many other parts of the developing world. The inability to pay for health care expenses, which forces people to reduce spending on food or other basic needs, and the lack of access to quality care are unfortunately common realities seen by many poor and underprivileged. Falling ill can have devastating and long-lasting consequences especially for poor households, both through income loss and high medical expenditures. Data suggest that more than 150 million people globally suffer financial catastrophe every year due to out-of-pocket health expenditures. Nigeria has among the highest out-of-pocket health spending and poorest health indicators in the world.
Most people would agree with the idea that all individuals should have access to health services and should not face financial hardship as a result of health care costs. Universal health coverage (UHC), the concept that encompasses these goals, has gained wide attention and support in recent years. How to achieve UHC however, is a more complex question with a variety of disparate viewpoints. In this paper, we discuss UHC in the context of Nigeria, a middle-income country that nevertheless is facing enormous health challenges. We discuss the constraints that have prevented Nigeria from attaining UHC to date. We then present promising evidence from large and small-scale insurance interventions in other parts of the developing world. Next, we describe a public- private partnership model of community-based health insurance currently operating in Nigeria and other parts of Africa and show evidence of the program’s ability to increase health care utilization, provide financial protection and improve health status in target communities. We contend that UHC in Nigeria can only be achieved by addressing both supply and demand-side constraints simultaneously. The solution must also include building on existing public and private institutions and informal networks, leveraging existing capital, and empowering clients and local communities. An innovative model such as the one presented here that has been implemented successfully in one Nigerian state, could be replicated in others; tackling this challenge one state at a time, to eventually achieve the goal of access to health care and financial protection for all.
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