AUGUST 2016 ABOUT THE AUTHORS OLUMIDE OKUNOLA, What’s in a Name? a Senior Health Specialist, manages the Nigeria program of A Lot—When It’s “Community-Based” the Health in Africa (HiA) initiative. He previously managed a large health-care Health Insurance in Nigeria infrastructure project in Nigeria. As global policymakers have refocused efforts to promote universal health KHAMA ROGO, coverage (UHC), prepayment for health services has emerged as a key to Lead Health Specialist with the World Bank Group, is the achieving sustainable and effective health systems. Community-based program manager of the HiA initiative, leading its work in health insurance schemes (CBHIS) have addressed this need for about 20 nine African countries. years, but they fall short of the goal. Meanwhile, the Nigeria National OLAMIDE OKULAJA, Council on Health (NCH) recently approved implementation of State- a consultant with the Nigeria program of the HiA initiative, Supported Health Insurance Schemes (SSHIS). These plans often include a has extensive experience working with several private “community” component, which has led to confusion of SSHIS with CBHIS. hospitals in information and communication technology This SmartLesson shares lessons from the implementation of critical reforms systems, financing, quality, human resource management, in Nigeria’s health systems and addresses the need to clarify the use of the and business development. term CBHIS in Nigeria. APPROVING MANAGER lenges with initiation, sustainability, Michele Gragnolati, Practice BACKGROUND Manager and Global Lead for and scale-up; they usually are unable Population and Development, Since the 1990s, CBHIS have been imple- to reach high levels of population cov- World Bank Health, Nutrition, mented in several African countries, in- erage; and with small and fragmented and Population Global Practice. cluding Burkina Faso, Ghana, Rwanda, risk pools, they most often require sub- 1 Senegal, and Tanzania, and some peo- sidies for poor and vulnerable segments ple see them as an “ideal” risk-pooling of the population. mechanism for minimizing catastrophic payments in low-resource settings, and As Nigeria looks toward achieving UHC ensuring responsiveness to local health through a strategy that recognizes a 2 needs. However, despite some ma- role for the states, with support from a jor accomplishments in countries with central equity fund, it is imperative that strong national-government steward- the terms CBHIS and SSHIS are clearly ship, most CBHIS have been limited in defined in the Nigerian context—with scope and success: they face major chal- lessons for other countries that face the same set of dilemmas due to confusion 1 Odeyemi, “Community-based health insurance programmes and the national health insurance scheme related to terminology. of Nigeria: Challenges to uptake and integration,” International Journal for Equity in Health 13, no. 20 Below are lessons from the implemen- (February 21, 2014). http://www.equityhealthj.com/ tation of critical reforms supported by content/13/1/20. the World Bank Group’s Health in Africa 2 H. P. P. Donfouet and P-A. Mahieu, “Community- Initiative (HiA) at the Nigeria National based health insurance and social capital: A review,” Health Economics Review 2, no. 5 (2012). http://www. Health Insurance scheme and close in- healtheconomicsreview.com/content/2/1/5; and H. volvement in the design and implemen- Wang and N. Pielemeier, “Community-based health tation of state schemes in Ogun, Kwara, insurance: An evolutionary approach to achieving universal coverage in low-income countries,” Journal Lagos, and Delta states. The program of Life Sciences 6 (March 30, 2012): 320–29. also assisted with closing the Bank- SMARTLESSONS — AUGUST 2016 1 supported Nigeria Pre-Paid Health Scheme pilot project with CAPDAN3 Box 1: CBHIS or SSHIS? in Lagos State. CBHIS have traditionally focused on rural and informal communities in the The extensive experience of the Ni- global South, empowering members to determine their benefits and partici- geria HiA in critical policy reforms pate in scheme management. This process is seen as revolutionary in reaching geared toward Nigeria’s UHC aspira- out to large swathes of underserved lower-income groups previously excluded from formal social security mechanisms. While CBHIS vary in design and orga- tions, and implementation of these nizational practice, they share five core characteristics focused on community state schemes provides insight for empowerment:a distinguishing clear differences be- tween CBHIS, as described by the lit- • Community-based social dynamics and risk pooling, targeting individuals erature, and state-sponsored health who share common characteristics (geography, occupation, and so on); insurance schemes as increasingly • Solidarity, where inclusion is independent of individual health risks; seen in Nigeria. Establishment of • Community participation in decision making and management; the first wave of SSHIS in Nigeria has • Nonprofit character; and • Voluntary affiliation. substantial community involvement, although they do not qualify as tra- The CBHIS concept owes its success primarily to the principles of solidarity and ditional CBHIS. The term CBHIS is a trust, aiming to optimize social capital within the community to achieve max- misnomer as used in several schemes imum population coverage.b But CBHIS, as defined, mobilize insufficient re- in Nigeria. (See Box 1.) sources, lack the technical capacity to go to scale, and exclude the poorest and those most in need.c Despite substantial government in- SSHIS, on the other hand, are initiated and supported by state governments. volvement, communities also play a They are usually pro-poor risk pools and are run either as an agency of govern- major role in the running of SSHIS. ment or as an independent government-funded agency. SSHIS provide re- It is this feature that has stubbornly sources to ensure that the poor and vulnerable are cared for, provide mecha- led to the continued use of the word nisms to ensure sustainability and viability, and are backed by significant “community” in referring to them. technical capabilities. They also ensure the platform for implementation of the (See Table 1.) critical partnerships with the national government, as seen in the support of premiums for the poor by the NHIS through the implementation of the Basic Health Care Provision Fund. LESSONS LEARNED The state has significant institutional and governance responsibilities, includ- ing defining benefit packages, empaneling providers, bearing financial risk, Lesson 1: Community partici- and supporting the payment of premiums for poor and vulnerable people. In pation is required for imple- Nigeria, the most singular unique characteristic of SSHIS is the enabling legis- mentation of a successful lation, which clearly provides the legal instrument for setting up such schemes. state-sponsored health insur- ance scheme to promote social a. Wang and Pielemeier. b. Donfouet and Mahieu (2012). capital and ownership. c. B. Ekman, “Community-based health insurance in low-income countries: A systematic review of the evidence,” Health Policy and Planning 19, no. 5 (2004): 249–70. http:// One of the key principles of func- heapol.oxfordjournals.org. tional CBHIS is the solidarity and trust between members, which mo- tivates members who are suscep- trustees (chairman, secretary, treasurer, and four tible to risk to put together their resources for com- others), elected from within each community for mon use. The following three examples illustrate a four-year term, manages the funds accrued in how states have implemented SSHIS with community the accounts of each (public) provider, together involvement: with the local government administration (LGA) board, and runs its own scheme. Each board em- • Ogun State. To ensure community participa- ploys a salaried scheme manager to administer tion and ownership in the Araya SSHI program day-to-day activities, including addressing the management, the state government put in place complaints of enrollees and being accessible to several democratically elected boards of trustees the public. Board members receive token incen- to represent and manage each scheme in each tives and are entrusted with identifying the vul- community. Each scheme consists of a maximum nerable groups (poor, aged, under-fives). Using of 4,000 enrollees. A seven-member board of tools provided by the state, the proposed groups 3 CAPDAN = Computer and Allied Product Dealers Association of are then verified to receive “free” health care. Nigeria. (See Figure 1.) 2 SMARTLESSONS — AUGUST 2016 Table 1: Comparative Analysis of CBHIS and SSHIS S/N Component CBHIS SSHIS 1. Funding Pooled at the level of the Pooled at the level of the state, with community significant government contributions 2. Membership Voluntary Voluntary/Mandatory 3. Reliance on an ethnic mutual aid/solidarity yes no 4. Legislative process no yes 5. Pro-poor component yes/no yes 6. Nonprofit objective yes yes 7. Risk pooling yes yes 8. Linked to a provider yes (usually public with no yes choice of private) 9. Donor support yes yes 10. Technical capacities and link to other state no yes institutions, such as Quality programs 11. Link to national/central governments/major no yes sponsor, such as the NHIS 12. Community participation for enrollment, yes yes marketing, and governance Source: Adapted from Donfouet and Mahieu (2012). Figure 1: Levels of Community Participation in the Ogun Araya Program Source: Nigeria