The hallmark of any developed nation committed to protecting the wellbeing of its citizens is ensuring there is inclusive and affordable access to health care services. In Nigeria, however, a vast number of individuals, particularly in rural communities, don’t have access to health facilities. They consequently die from preventable deaths. And the deterrent to healthcare use remains, cost.
Realistically, not everyone plans for medical services, especially emergencies. When you take to consideration the prevalent fiscal paucity, accessing aid in medical emergencies can then be a resource challenge to most people. Experts have since tackled the relationship between health expenditure and poverty.
Enter CBHIS… The international community regards the CBHIS as an instrument that keeps members of rural communities afloat and assures them basic healthcare in a prepaid plan. Community-based health insurance schemes are an especially important tool in developing nations where significant portions of the population live below the poverty line.
What is the CBHIS?
Community-Based Health Insurance Schemes are micro-financing involving a revolving loan scheme for the community to use towards healthcare. Community members voluntarily pool their risks in anticipation of payouts to off-set vulnerabilities, in this case, a health vulnerability; premiums are modest and variable, and the agency for administering the CBHIS is accessible at the community level. Further, enrolment is voluntary and based on the perceived benefits of the system. The scheme finds its roots in the traditional notions of reciprocal care and support.
In 2017, a report by the Centre for Health Economics and Development (CHECOD), tested out the feasibility of the CBHIS. The findings were a mixed bag. While 66% of households in the North-East state of Yobe could partially pay for medical services, more than half of Bauchi’s residents could not afford said services. In fact, 70% of these respondents reportedly sought financial support if their medical bills scaled up to N2000. About 98-99% of indigenes in Benue and Kwara paid for medical treatments out of pocket. Conversely, the report observed community donations and charity payments as the backbone for health payments in Plateau and Niger state, with the later recording over 48% residents financed this way; the other 63% borrowed.
CBHIS: Feasibility & Implications
Findings from the CHECOD report showed that in the North East, North Central and South-East geopolitical zones, on average, half (50%) of the people in these communities will contribute N200 towards their CBHIS. The contribution was measly, yet these were the drops that would make a sea of difference.
The report also showed that a larger percentage of the households in the North West, South West and South-South zone will pay toward the insurance scheme. Kaduna, Jigawa, Kano, Katsina, Kebbi, Sokoto, Osun, Ekiti, Ondo, Ogun, Oyo, Akwa Ibom, Bayelsa, Delta, Cross River, Edo and Rivers were all states with over 90% of the households willing to pay a sum of money.
What this shows is that there is a disparity in the willingness of communities to take part in a CBHIS based on their geopolitical zone. However, findings remain muddy as the research only accounted for a regional analysis, failing to examine individual communities and their socioeconomic status as a deterrent from their CBHIS participation.
Experts take
In a bid for further clarity, Dataphyte reached out to Dr Obioma Obikeze, a Health insurance expert with over 10 years of experience in the field and Programme Coordinator for the National Health Insurance Scheme (NHIS) in Bayelsa State. In his words:
“CBHIS was designed ab initio to provide health insurance for people who do not have formal employment… CBHIS, and of course any health insurance is based on solidarity. Let those who are well today help pay for people who are sick today because tomorrow may be their turn, and those who are healthy tomorrow will be there to help them. That is the basic essence of health insurance.”
According to Dr Obioma, it is always relevant to look at the past and note what worked and why”. This information will help determine why Nigeria is still yet to utilise this tool. He further noted how the government had started different pilot community-based health insurance schemes in many parts of Nigeria including Abia, Anambra, Niger, Enugu, FCT and Lagos. “Amongst these none has sustained itself. In every instance, once there were no longer subsidy donations, the scheme failed as the community could not show ownership and maintain funding,” Dr Obioma noted.
What makes a good CBHIS?
Dr Obioma further outlined certain criteria that would aid in identifying an effective CBHIS. He first highlighted the number of persons involved to be of significance: “the survival of any insurance is a factor of number.” If the number of people taking part is large, a community will have enough to purchase the benefits package or necessary components of care.
Another factor is the quality of care the scheme affords its consumers. He said,
“if the care you receive today is excellent quality, chances are you would like to renew your premium when it expires; but if the quality is poor, (sub-par) chances are you would not like to go back to that healthcare provider when next you need care.”
Last, Dr Obikeze listed efficiency and effectiveness as criteria for a good CBHIS, particularly regarding management responsible for deciding on the benefits package for communities. Ineffective management leads to poor fiscal allocation. “These three have to work hand-in-hand, each performing at its best,” he remarked.
Are we asking the wrong questions?
When asked to comment on the feasibility of CBHIS and the willingness of communities to take part, Dr Obioma raised many important points. He said,
“the Nigerian populace has not completely understood the benefit of health insurance, and it goes to show the level of trust of the citizens upon the government.” Interestingly, he raised the question that perhaps we are looking at the wrong place entirely. He explained that “willingness to pay differs from readiness to pay.” “The percentages seen in the [CHECOD] report is what you call total willingness to pay. When it comes down to getting communities to pay this money, we will see even fewer percentages.”
It’s also just “a function of the understanding of the benefit of health insurance among the populace.” People’s willingness to pay for a particular good is a function of their perceived value of the good.
How can the government streamline the CBHIS instrument to support her indigents?
First, those who make up members of CBHIS as contributors or beneficiaries or healthcare consumers must realise its benefits. “The government needs to show to the people that CBHIS is the most efficient way of spending healthcare money,” Dr Obioma noted.
Dr Obioma also remarked on how not making CBHIS mandatory is a flaw. He explained this by citing the phenomenon in health insurance “where people most likely to fall ill are the people who buy the insurance, and those who are healthy shun insurance.” Thus, only those likely to be ill will buy insurance; in that regard, they miss a big subsidy in the healthy paying for the poor on account of the scheme being optional.
In his last remarks, Dr Obioma said,
“Nigeria can do well in its universal health coverage (UHC) journey if it harnesses available health financing opportunities (the type created by section 11 of National Health Act through the Basic Health Care Provision Fund – BHCPF) while developing new ones at the States and Local Government Area (LGA) levels. The government designed the BHCPF to deepen primary health care (PHC) financing across the country. Replicating initiatives like BHCPF in each State of the country and Federal Capital Territory (FCT) through robust State Health Insurance (SHI) laws will be a great value addition across the country.”
He also noted that,
“creating health insurance fund pools like BHCPF in every state will increase the confidence of the international development community with increased likelihood of targeted donations for subsidy financing for the informal sector. The ongoing National Health Insurance Commission (NHIC) Bill 2019 at the National Assembly appears to be an opportunity to make health insurance enrolment a compulsory venture for all Nigerians while using BHCPF and similar arrangements as important vehicles for providing subsidy for the informal sector persons that cannot pay a premium for care.”
Synergy at all levels
From the preceding, the government needs to take several actions at various levels to ensure that voluntary CBHIS work at community levels. While the Federal level has a deep responsibility to create health insurance architecture through the BHCPF; at the state and community levels, there is a need to educate communities of the benefits of such schemes. Similarly, there is a need to instil confidence by ensuring that community-based providers are efficient and effective. States must ensure that communities trust the quality of care provided by regulation and quality control.