The high burden of diseases in Nigeria is largely attributable to grossly inadequate funding for health in the country. Nigeria’s health financing landscape is characterized by suboptimal public investment in health as the government spends less than 1% of the country’s GDP on health, which is among the lowest in the world, and allocates less than 5% of the national budget to health as against the 15% benchmark. Suboptimal coverage of financial protection mechanisms is another feature of Nigeria’s health financing system as less than 5% of the population is covered by any form of health insurance. A review of the health system financing for Universal Health Coverage (UHC) in Nasarawa state shows 95.7% out-of-pocket expenses for health care in 2017 and a very low budget for health at the state level3. This high proportion of out-of-pocket spending prevents many residents from seeking medical help in the first instance and many do experience financial hardship in the process of seeking health care. Several policy thrusts aimed at increasing funding for health, providing financial protection for the populace, and generally setting the country on the UHC trajectory have been introduced at the national and sub-national levels. However, the Local Government Areas (LGAs) and communities hardly feature in the design and implementation of such policy thrusts. Therefore, the government and citizens at the LGA and community level need to be sensitized on the available policy thrusts. Also, considering that the poorest and most marginalized people have the greatest need for health services, they should be prioritized in the interventions aimed at promoting UHC.
To address these challenges, the following interventions were implemented through the Christian Aid’s UHC program implemented by DGI Consult in four wards (Tundun Kofa, Yara, Angwan Rimi and Sabon Gari) in Keffi LGA, Nasarawa State:
- Baseline assessment of the Basic Health Care Provision Fund (BHCPF) accredited health facilities to determine their service utilization rates, understand the health-seeking behaviour of the populace, and identify the level of financial hardship associated with health care in the four implementation wards
- Identification of 40 Community Resource Persons (CRPs) that include the Ward Development Committee Chairmen (WDC), Officers-in-Charge (OICs) of each of the BHCPF-accredited facilities, and representatives of selected community social structures across the four wards
- Capacity building of the CRPs on the promotion of health insurance in the community through community mobilization, advocacy, and resource mobilization for enrolment of the poor and vulnerable
- Adoption of 440 poor and vulnerable persons (including women, children, elderly, and people living with disability) under the Nasarawa State Health Insurance Scheme (NASHIS) across the four wards
- Effective monitoring of service availability and utilization across the BHCPF-accredited health facilities in the four wards by routine physical visitations, monthly meetings, and follow-up calls.
- Facilitating strategic engagement of Nasarawa State Health Insurance Agency (NASHIA) and Nasarawa State Primary Health Care Development Agency (NAPHCDA) with community resource persons, to address demand and supply-side issues.
- Sensitization of existing informal sector groups and religious organizations on the concept of universal health coverage, benefits of health insurance and payment of health insurance premium for the poor and vulnerable members of the groups
- Effective community engagement through mobilization and sensitization of community members on the benefits of health insurance, and advocacy to influential personalities on resource mobilization for the enrolment of the poor and vulnerable people in the community.
a. Combining effective community engagement with purchase of health insurance premium for the poor and vulnerable population has led to increased service utilization across the four implementing facilities. This is evidenced by an increase in the facility utilization rate among the beneficiaries of the Christian Aid UHC project compared to unenrolled community members and beneficiaries of other pro-UHC programs such as BHCPF and Equity Fund (Figure 1). As a case in point, consultation per person per year among unenrolled community members at PHC Kofar Pada was 0.8 which means it will take more than a year for every member of this population to access health facilities once whereas, enrollees of the UHC Project, BHCPF and Equity Fund will access care 5.3, 3.4, and 2.7 times respectively in a year.
Figure 1: Facility Utilization Rate (Based on 3months of Health Service Utilization)
b. Facilitating providers’ engagement provided an avenue for the NASHIA and NAPHCDA to meet the representatives of the facilities and communities to discuss and resolve supply and demand-side issues. This has resulted in improved service delivery, particularly the referral process for enrollees of the health insurance scheme.
c. Advocacy to influential personalities led to the adoption of 8 (eight) community members and commitments to adopt more poor and vulnerable community members under the Nasarawa State Health Insurance Scheme
d. Propagating beneficiaries’ good experiences aids community sensitization on the importance and benefits of health insurance. It also serves as an advocacy tool for mobilizing resources for the adoption of the poor and vulnerable people on the health insurance scheme. In addition, the testimonies of some beneficiaries have allayed the fear of sensitized community members on the reality of health insurance. Below are some testimonies received from the beneficiaries:
“I am one of the beneficiaries of this program, I was very sick, and went to my assigned PHC in Yara ward and I was referred to Nagari hospital because they said I have severe asthma. In Nagari hospital, they did X-ray for my chest, they gave me drugs and everything. I am now much better and I did not pay any money. Ordinarily, I was to pay from out-of-pocket, I am sure I would sell personal belongings and borrow money, because Nagari is one of the most expensive hospital in Keffi but under this project and with the help of NGN12,000 through insurance, I have been well taken care of, and I still have more services to utilize before the insurance expires. I even went there twice, and they gave me oxygen without paying anything”-Hussaina Atiku
“I was having malaria and typhoid, I went to Tundun Kofa PHC with my card, and they attended to me very well, I did not pay money for anything, I am very satisfied” –Abubakar Wada (PLWD)
“I was having problem of malaria, I went to Agwan Jaba Primary Health Care, after doing test, they gave me drugs free, everything was free” –Halimatu Muhammed
- Facilitating strategic engagement of NASHIA and SPHCDA with service providers helps to provide lasting solutions to supply-side issues
- Combining effective community engagement with health insurance enrolment translates to higher facility utilization than health insurance enrolment alone
- Positive feedbacks and testimonies from beneficiaries are essential to propagate campaign messages for health insurance enrolment
- Continuous follow-up with beneficiaries facilitated an increase in service utilization
- Communication of UHC campaign messages in the local language (Hausa) enhanced the ability of the community resource persons and the sensitized groups to understand the UHC campaign messages
Strategic advocacy, continuous community engagement and effective follow-up are important for increasing the enrollment drive for State Health Insurance Scheme. Also, domestic resource mobilization through advocacy to influential members of the community, informal sector groups and religious organizations will help to subsidize healthcare for the poor and vulnerable people in the community. In addition, effective engagement of enrollees is crucial to ensure that they utilize health services. These will contribute significantly towards putting the country on the right track for achieving UHC at the grassroots.
 WHO Global Health Expenditure Database, 2017
2 World Health Organisation (2017). Universal Health Coverage. http://www.who.int/healthsystems/universal_health/coverage/en/
3 Ogye D. O., Attah, A. P. and Ali, M. A. (2019) Financing health care in Nasarawa state, Nigeria: Assessment of the Universal Health Coverage (UHC) (IJPAMR) 5(1):120-133.