By Sekinat Sanusi
Program Officer, DGI Consult
Universal health coverage is a top priority on the global development agenda as evidenced by its inclusion in the Sustainable Development Goals. Despite the widespread global support for universal health coverage, Nigeria is progressing at a slow pace in achieving this goal, largely due to insufficient health funding. Nigeria’s health finance landscape is marked by insufficient public investment in health, with the government spending less than 1% of GDP on health, which is among the lowest in the world and allocating less than 5% of the national budget to health, in contrast to the 15% target.1 The suboptimal public investment in health coupled with low coverage of financial protection mechanisms creates a situation where out-of-pocket expenditure accounts for more than 70% of the total health expenditure. This is quite alarming considering that a significant proportion of service users will experience financial hardship once this figure exceeds 30% threshold.
At the national and subnational levels, several policy thrusts aimed at improving health funding, providing financial protection for the population, and putting the country on the UHC trajectory have been introduced. Some of these policy thrusts are Basic Health Care Provision Fund (BHCPF) and health insurance decentralization that ushered in State Social Health Insurance Scheme. Despite the implementation of these policy thrusts, less than 5% of Nigerians most of whom are belong to the formal sector have health insurance. There is a huge gap in the coverage of the informal sector population which comprises the poorest and most marginalized people who have the greatest need for health services. Providing efficient population coverage towards attaining UHC necessitates identifying poor and vulnerable groups, sensitizing them on the importance of good health-seeking behaviour, and ensuring that they have physical and financial access to required healthcare services2.
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 service utilization rates, understand population health-seeking behavior, and identify the level of financial coverage and hardship associated with health care in the four implementation wards
- Identification of 40 Community Resource Persons (CRPs) including the Ward Development Committee Chairmen (WDC), Officers-in-Charge (OICs) of each of the selected 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 selected BHCPF-accredited health facilities by routine physical visitations, monthly meetings, and follow-up calls.
- Facilitating strategic engagement of Nasarawa State Health Insurance Agency (NASHIA) and Nasarawa State Primary Healthcare Development Agency (NAPHDA) with the 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.
- Combining effective community engagement with the 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).
Figure 1: Facility Utilization Rate (Based on 5months of Health Service Utilization)
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.
- Facilitating providers’ engagement provided an avenue for the NASHIA and NAPHDA 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.
- Advocacy to influential personalities led to the adoption of sixteen community members and commitments to adopt more poor and vulnerable community members under the Nasarawa State Health Insurance Scheme
- Propagating beneficiaries’ good experiences aided community sensitization on the importance and benefits of health insurance. It also encouraged the religious/informal sector groups and influential members of the communities to pay premium for some poor and vulnerable people.
- Regular interface of the government agencies with the service providers and representative of the communities 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
- Communication of UHC campaign messages in the local language enhances the ability of the community resource persons and the sensitized groups to understand 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.
Mobilization of grassroots and communities to influence national and sub-national policies is essential to achieving health system reforms and ensuring that no one is left behind.
The following actions are recommended to accelerate progress towards achieving UHC in Nigeria:
- Leverage existing community structures to increase community awareness on the concept of UHC and what achieving UHC would entail for individuals and communities.
- Promote health systems strengthening by building partnerships and creating interface of policymakers, government agencies and healthcare providers with the communities, while encouraging participatory decision-making and fostering local ownership.
- Conduct continuous advocacy to increase meaningful community engagement and engagement of social minorities in political dialogues and decision-making.
- Support advocacy efforts by sharing lessons learned, testimonials and messages that have proven effective and by providing context appropriate resources for community engagement activities.
- WHO Global Health Expenditure Database, 2017
- Asian Development Bank (2016). National Health Insurance for Universal Health Coverage. Asian Development Bank (ADB) Headquarters, Manila, Philippines