Scaling up Community Based Health Insurance Scheme: Nigerian Experience

towards Universal Coverage

Presentation at African Health Economic and Policy Association

ConferenceSaly, Senegal

15th– 17th March, 2011

Kenneth Ojo & Paul AngbazoPartnership for Transforming Health Systems 2 (PATHS2) Abuja, Nigeria

Background The need to address the challenges of health care

financing for universal financial protection in Nigeria, The current scheme in Nigeria started with a mandatory

health insurance for the federal civil service through National Health Insurance Scheme

Overall coverage is about 3% of the Nigerian population It is therefore apparent that there is a need to provide

sufficient financial risk protection to the rest of the uncovered population against the cost of health care.

Governments at all levels already identified the need to support the scaling-up of risk pooling mechanisms in the health sector and the development and expansion of community based health insurance to achieve universal coverage.

There is need generate evidence for decisions on scaling up

Current efforts at scaling up

1) Inventory study of CBHIS and other Social Solidarity Groups by NHIS

2) Development of some schemes by some states governments – Lagos, Kano, others

3) Communities and Private Sector Initiatives in the establishments of some schemes

In what direction is the current analysis of scaling up CBHIS?

Economic framework focusing on willingness-to-pay, information, price and quality

Health system framework: institutional context of the health system, analyzing interactions between insured, insurance schemes, health service providers and the government

Are these necessary and sufficient conditions for scaling up and sustainability of the CBHI schemes?

What can we learn from the social framework/determinants or a combination of the three in understanding the essential factors for scaling up and sustainability of the CBHI schemes ?

What are missing links between theory and policy for scaling up?

Can Economic theory take into account context-dependent policy considerations through the theory of Social Capital?

Can Willingness to pay be increased by solidarity bonds and should be purely understood in neoclassical economic terms, where willingness to pay is based on individual expected utility?

Can the complex interplay between rational utility maximizing and socio-cultural norms (such as solidarity, collective action) probably affects individuals’ decisions to join a scheme?

Can we argue with evidence that social capital facilitates collective action and willingness to pay?

What should be the role of government in widespread coverage through CBHIS?

Looking at Social Capital Social capital – a measure of how much people within a society are

willing and able to help each other – is regarded as an important determinant of individuals’ willingness to pay for CBHI (along with expected economic and quality gains);

Willingness to pay in turn is a key determinant of whether or not a CBHI scheme is feasible and sustainable.

Social capital can be operationalized in four dimensions: inter andi. links within communities/ inter-community bonding social capitalii. links between communities/ intra-community bonding social capitaliii. links between different institutions/ Micro level bridging social

capital: vertical and horizontal civil society links and iv. links between governments and their citizens/ Macro level bridging

social capital

NHIS inventory study to generating evidence for strategic decision making on

scaling up

Specific Objectives: Identify the numbers, size,

characteristics of all existing CBHIS and other social solidarity organizations with similar characteristics with the CBHIS and examine the potentials and policy implications for transforming them into viable CBHI schemes

Identify other civil society groups, who could play roles in the mobilization and sensitization of communities for CBHIS.

Methodology for NHIS inventory

This study covers all the existing CBHIS in terms of mapping and detail analysis in all the six zones of Nigeria.

Mapping all the identifiable CSOs in the each zone and sampled for detail analysis 25 CSOs (where there are more than 25 and all where the CSOs are less than 25)) in each Local Government Area (LGA).

Stratified sampling covering all the 8 categories of CSOs :group one has Cooperatives societies, Trade unions and Artisans and group two has Gender based NGOs ,CBOs, CDAs and Foundations

CLASSIFICATION OF CSO

International Non-governmental Organizations (NGO) Non-governmental Organizations (NGO) – national- Broader

focus and target audience; more structured; registered Faith-based Organizations (FBO) - Religious affiliation; more

structured; registered Community-based Organizations (CBO)- Community-based

and focused; some structure; some registration Community Development Associations (CDA) Social Solidarity Groups Alumni Associations; Friends’ Clubs; Community

Associations meeting outside the community; etc Cooperative Societies Professional Associations – Accountants, nurses, doctors,

etc Trade Unions

Characteristics for Considerations 1

• Social and economic context• Management and organization structure• Core focus of the group; aims and objectives• Membership- size, types, composition and

coverage• Health Benefit package in the scheme• Health care provision issues-drugs, human

resources, facilities, quality of services• Provider payment mechanism• Financial management, accounting and

control

Characteristics for Considerations 2

• Contribution mechanism• Size of funds available• Investment capacity• Supervision, monitoring and evaluation• Promotion and marketing the scheme• Role of government and other regulators• Risk management issues- adverse selection,

moral hazard, fraud, cost escalation• Equity issues• Sustainability issues• Challenges faced by the scheme

BASIC PRINCIPLES OF COMMUNITY BASED HEALTH INSURANCE

Autonomy Not for profit Solidarity Democratic decision making and

accountability Risk sharing Responsibility Social movement

OVERVIEW OF CIVIL SOCIETY ORGANIZATIONS (CSOs)

Civil Society Organizations (CSOs) are non-governmental, not-for-profit, voluntary organizations formed by people within the social sphere of the society

They cover a variety of organizational interests and forms, ranging from formal organizations registered with authorities to informal social movements coming together around a common cause

The key characteristics of CSOs

Non-governmental Voluntary Non-political Not-for-profit Common focus Target Audience Benefit of others Non-religious (except FBOs) Membership-based (not all)

Evidence from the survey:Total Number of CSOs Identified by Categories in South West

Cooperative Trade Artisan Prof. Association FBO Gender NGO/ CDA Foundation0

500

1000

1500

2000

2500

3000

3500

4000

Categories

Number of CSOs Identified by Categories

EKITI LAGOS OGUN ONDO OSUN OYO

Cooperative Societies 60 895 162 21 1843 369

Artisan 193 85 1 76 91 240

CDA 132 0 20 188 1475 948

100

300

500

700

900

1100

1300

1500

1700

1900

Num

ber

of

CSO

CATEGORIES BY WHO INITIATED THE ORGANIZATION

Coope

rativ

e So

cietie

s

Trad

e Uni

on

Artisa

n Ass

ocia

tion

FBOs

Gende

r Bas

ed

NGOs CBOs

CDA

Foun

datio

n0

50

100

150

200

250

300

350

Categories of CSOs

IndividualGroupGovernmentCommunityTraditionalInsitutionOthers

Years of Existence of Organizations

0-5 years 6-10 years 11-25 years 26-50 years 50 years above0

100

200

300

400

500

600

AREAS OF WORK OF ORGANIZATION BY STATE

EKITI LAGOS OGUN ONDO OSUN OYO

Yes 18 34 36 51 154 180

No 79 145 85 97 307 309

25

75

125

175

225

275

325

States by Working on Women Issues

AREAS OF WORK OF ORGANIZATION BY STATE 2

EKITI LAGOS OGUN ONDO OSUN OYO

Yes 74 139 86 115 312 379

No 25 40 36 33 150 111

25

75

125

175

225

275

325

375

States by Working on Social Issues

CATEGORIES BY OBJECTIVES

Cooperative Societies

Trade Union Artisan Asso-ciation

FBOs Gender Based NGOs CBOs CDA Foundation

Yes 233 78 44 11 14 30 55 6

No 152 166 161 51 45 126 207 18

25

75

125

175

225

Categories of CSOs by Poverty Eradication /Granting of Loans/ Revenue generation

CATEGORIES BY OBJECTIVES 2

Cooperative Societies

Trade Union Artisan Asso-ciation

FBOs Gender Based NGOs CBOs CDA Foundation

Yes 271 194 165 30 34 88 86 12

No 115 51 40 32 25 68 176 12

25

75

125

175

225

275

Categories of CSOs by Members Welfare/Improve Standard of Living/ Improve Members

SOURCE OF INCOME BY DIFFERENT CATEGORIES OF CSOs

Cooperative Societies

Trade Union Artisan Asso-ciation

FBOs Gender Based NGOs CBOs CDA Foundation

Yes 405 255 230 56 51 129 271 13

No 14 13 6 15 10 41 9 10

25

75

125

175

225

275

325

375

425

Categories of CSOs by Membership Contribution

SOURCE OF INCOME BY DIFFERENT CATEGORIES OF CSOs 2

Cooperative Societies

Trade Union Artisan Asso-ciation

FBOs Gender Based NGOs CBOs CDA Foundation

Yes 157 133 110 57 38 119 162 18

No 262 135 126 14 22 51 117 4

25

75

125

175

225

275

Categories of CSOs by Donations

TYPE OF MEMBERSHIP BY CATEGORIES OF CSOs

Cooperative Societies

Trade Union Artisan Asso-ciation

FBOs Gender Based NGOs CBOs CDA Foundation

Yes 308 207 199 55 54 147 211 18

No 110 63 38 14 7 24 68 3

25

75

125

175

225

275

325

Categories of CSOs by Individual

TYPE OF MEMBERSHIP BY CATEGORIES OF CSOs 2

Cooperative Societies

Trade Union Artisan Asso-ciation

FBOs Gender Based NGOs CBOs CDA Foundation

Yes 182 124 93 38 26 65 133 6

No 236 145 144 32 35 106 145 15

25

75

125

175

225

Categories of CSOs by Group

CATEGORIES OF CSOs BY MEMBERSHIP TYPE

Cooperative Societies

Trade Union Artisan As-sociation

FBOs Gender Based

NGOs CBOs CDA Foundation

Voluntary 391 171 98 63 56 161 233 20

Compulsory 27 98 140 7 6 10 44 1

25

75

125

175

225

275

325

375

425

Categories of CSOs by Is Membership Voluntary or Com-pulsory?

Evidence of Government role and support to CSO

Stewardship :regulation & monitoring;

Creating an enabling environment: rule of law, advocacy, information sharing, aid communities in constructing social capital to create better conditions for CBHIResource transfer: subsidies, incentives, facilities etc

ROLE OF GOVERNMENT IN THE ESTABLISHMENT BY CATEGORIES OF CSOs

Cooperative Societies

Trade Union Artisan Asso-ciation

FBOs Gender Based NGOs CBOs CDA Foundation

Yes 250 123 81 25 25 50 160 4

No 168 145 156 45 37 121 119 16

25

75

125

175

225

275

Did the Government have any Role in the Establishment

SUPPORT BY GOVERNMENT TO DIFFERENT CATEGORIES OF CSOs

Cooperative Societies

Trade Union Artisan Asso-ciation

FBOs Gender Based NGOs CBOs CDA Foundation

Yes 222 105 52 24 22 48 165 3

No 82 66 103 20 16 41 42 6

25

75

125

175

225

Does the Government Povide any Support to your Organization

What can we learn from the preliminary analysis

Evidences generated suggest that four categories of organizations, namely, Cooperative societies, Community Development Associations, Trade unions, and Artisans organizations are adaptable for participation in CBHIS .

Two categories of organizations; Community Based Organizations and Gender Based organizations would be useful partners in community mobilization and sensitization.

NGOs and Foundations may be useful partners for mobilization and technical support.

The need to develop appropriate advocacy and communication strategy to engage with these organizations

Government roles should be clearly defined