COMBINATION OF HEALTH INSURANCE AND EFFECTIVE COMMUNITY ENGAGEMENT: A PATH TO ACHIEVING UHC GOALS AT THE GRASSROOTS
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.
- The State Social Health Insurance Scheme (SSHIS) scorecard is an initiative of DGI Consult aimed at regular monitoring of SSHIS implementation status across the states of the federation. Collaboration with the Nigeria Governors’ Forum and the Executive Secretaries of the various States Health Insurance Schemes facilitated the use of this scorecard in monitoring the progress of SSHIS design elements for the various States by key stakeholders. The dissatisfaction of Osun State Governor at the State’s progress depicted on the scorecard prompted the timely release of N150 million take-off grant for the State’s health insurance scheme. Also, the government has approved its 3% contribution to public servants’ plan. The take-off grant will ensure effectiveness in health insurance operation in the state by the government and would be used for the establishment of Osun Health Insurance Business and Zonal Offices across the 69 Local Government Areas, Local Council Development Authorities and Area Councils. Subsequently, the Osun Health Insurance scheme has commenced enrolment and this would impact positively many lives across the State.
Live Tweet Chat on Next Level of Health Care Delivery in Nigeria: Keeping the Promise
In line with the theme of Universal Health Coverage (UHC) Day 2019 “Keep the Promise”, DGI Consult commemorated the day with a live tweet chat on “Next Level of Health Care Delivery in Nigeria: Keep the Promise”, for the audience to discuss, scrutinize and appraise the status of the Next Level Agenda for Health in Nigeria, and hold the government accountable to keeping the promises. These include:
- Health Insurance for all using co-payments to share the cost between individuals, the private sector and government, and exempting the poorest 40% from the co-payments
- 1% of Consolidated Revenue Fund to Health – The Basic Health Care Provision Fund in compliance with the National Health Act
- Increasing Population Coverage by Primary Health Care from the present 12.6% to 45% by 2023 via N500 monthly contribution
- Incentivizing young doctors to stay in rural areas (APC Manifesto 2019)
In assessing the level of progress towards UHC Goal in Nigeria, we asked our audience to discuss the reasons we are not making significant progress with the current state of our health indices. These include increased malaria cases by over 1 million cases between 2016 and 2017 (World Malaria Report 2018), increased under-5 mortality rate from 128 deaths in 2013 to 132 deaths per 1,000 live births in 2018 and only 2% increase in contraceptive prevalence rate between 2013 and 2018 (NDHS 2018).
Many found the increase in malaria cases unsurprising for different reasons, most notable of which is the questionable quality of malaria data in the country.
“The major problem is DATA. A lot of interventions centered around combating malaria are practiced nationwide but are not properly tracked due to the poor data system. A lot of the information reported lack accuracy and reliability”- Luca Brasi
The solution suggested that is to make data collection digital to adequately track and assess progress and develop a robust monitoring & evaluation (M&E) Framework for malaria control nationwide.
Another reason stated was misdiagnosed malaria cases in Nigeria which could be attributed to the absence of rapid diagnostic test (RDT) kits, questionable sensitivity of RDT kits and lack of an M&E system that checks the quality of malaria diagnosis. Although some publicly-owned health facilities have an M&E system for malaria diagnosis, they are not strictly adhered to. The absence of regulations in some private hospitals and unaccredited facilities also contribute to the misdiagnosis of malaria. Addressing these institutional challenges would be useful towards improving quality of malaria diagnosis.
Also, the need to adopt more elimination strategies for malaria in Nigeria was reiterated, as efforts are currently deployed towards diagnosing and treating malaria cases, whereas there should be more efforts and investment towards eliminating the causative agent of malaria through vector control.
On the issue of low contraceptive prevalence rate (CPR), respondents were of the opinion that the CPR in Nigeria is not reflective of efforts being made, and several social and economic factors hinder progress. These include illiteracy, religious and cultural beliefs over medical knowledge, myths about family planning, non-involvement of women in health decision making, poverty, etc.
“Many faiths do not embrace the idea of contraception and there are so many myths our people have concerning family planning especially with the side effects and the negative implications of users, I once conducted a FGD among artisans and more than 50% of them swore never to use FP because of the belief it encourages promiscuity and weight gain among females” Dr. Aderibigbe Adebayo
These issues need to be addressed through Behavioral Change Communication to change the perception of people towards family planning and facilitate more acceptance of contraceptives. Thus, the need for continuous re-engagement of relevant stakeholders who need to be correctly informed about family planning and also become key family planning support advocates was emphasized.
“Advocacy is key to disabuse the mind of people against the commonly held belief that “family planning encourages promiscuity”. Relevant government agencies, traditional & religious institutions and other stakeholders should drive this process” – Ojo Adeniyi
Some respondents also believed that health education especially amongst teenagers would help reduce teenage pregnancies and STIs, and stated the need for political declarations to be implemented through innovative health financing, accountability and ownership at State, Community and household levels.
After the assessment of progress of the Nigeria health system, we moved to discuss what needs to be done to take Nigeria from the current state to UHC2030. The respondents acknowledged there are multi-factorial issues and deficits in Nigeria that currently make UHC difficult to achieve but it is not impossible. Some of these issues include overpopulation and distance of tertiary health facilities from majority of the populace, the lack of infrastructure, low quality of services and human resources in primary and secondary health facilities which are often located closer to the people. Other important factors include an inefficient health workforce from the brain drain in the health sector, i.e. migration of many health professionals to other countries, questionable quality of drugs and other medical commodities, and the affordability of healthcare.
Many recommendations were proposed for moving Nigeria closer to UHC, some of which involved identifying and addressing political and economic bottlenecks towards achieving UHC. Government at all levels need to work on improving all the building blocks of health system and health insurance should be made mandatory to promote affordable health care, especially among the poor and informal sector. The presence of parallel health interventions for a common purpose should be discouraged, and coordination of efforts within the health sector from both government and partners is required to ensure synergy in achieving desired results.
Likewise, citizens have a key role to play in achieving UHC2030 by demanding quality and affordable health care. Thus, advocacy to the general public especially the informal sector to enroll and contribute to health insurance schemes is of utmost importance.
“……by sensitizing Nigerian citizens to demand affordable and quality healthcare as a criterion for winning elections as opposed to only infrastructural developments” Society for Family Health
On the issue of holding the government accountable to keeping the promise, our audience suggested mechanisms to do this and ways to enforce them. These include promoting accountability by building audit systems into every aspect of medical care with periodic reviews of the system to ensure sustainability. Also, the civil society and the populace must stand as one to continually monitor the implementation of policies set by the government against proposed timelines by sharing information about levels of progress that are apparent at the grassroot levels, strengthening the voice of CSOs and encouraging dialogue between citizens, health professionals and policymakers.
“@Connected_dev and @TrackaNG are already doing a lot in terms of public expenditure tracking. They can do more in the health sector provided a well-defined scope is developed to aid their activities” – Ridwan Olowookere
With functional state social health insurance schemes, coordination of interventions, change in behavioral thinking of citizens, investment in human resources for health, and efficiency in the use of available resources available for health, Nigeria would be closer to achieving UHC 2030.