Universal Coverage: Reflections of a missed opportunity in Rivers State, Nigeria

1. Universal Coverage: Reflections of a missed opportunity in Rivers State, Nigeria Tarry Asoka – 2nd Conference of African Health Economics and Policy Association (AfHEA) 15th – 17th 2011, Palm Beach Hotel, Saly, Senegal

2. Introduction • Universal access to health care will improve health outcomes in SSA • Adoption of social health protection mechanisms is a fundamental step (WHO, 2008) • Method of achieving this is irrelevant as long as people are protected from financial risk of ill health • In Rivers State, Nigeria – a planned social health insurance model aimed at universal coverage was set aside for social services trust fund • What went wrong? What measures should have been taken to safeguard the programme?

3. Methodology • A single case study – Rivers State Health insurance Programme (RSSHIP) • Narrative inquiry - to make sense of the relationship between human actions and the social context in which they have occurred. • Main sources of data - a personal account of the author who provided technical assistance and guidance to the programme from inception, as well as documents (reports, minutes of meetings, programme memorandum, draft law etc) that were produced in the planning process. • Additional feedback from the main actors

4. Case Report – Rivers State Health Insurance Programme (RSSHIP) The Background Context – Political economy and Institutional Analysis • Rivers State (pop.5.1m) - one of 36 States in Nigeria that has considerable resources and autonomy • State capital, Port Harcourt – centre of oil & gas, 3rd major business city after Lagos & Abuja • State was at the center of an intense struggle for supremacy among competing political interests • Emergence of a new Governor in October 2007 following a landmark Supreme Court judgment was seen as a new opportunity to provide better governance through a process of rational planning

5. Case Report – RSSHIP II Conceiving and Developing a Social Health Insurance Programme • Health Summit - Governor outlined his expectations from the conference and also agreed to implement recommendations as coming from the people. • A major recommendation from the Health Summit - establishment of a ‘Health Fund’ to finance health care in the State on a sustainable basis • Rivers State Health Policy & Health Financing Conference – proposed the establishment of RSSHIP

6. Case Report – RSSHIP III • Study tour of the country to consult with relevant institutions, as well as field visits to similar schemes • Executive memo approved by State executive Council • Commissioner of Health set up a technical committee to design the programme • Technical committee – programme memorandum, draft bill, and plan of action for implementation • Draft bill reviewed by legislative drafting unit of Ministry of Justice

7. Case Report – RSSHIP IV Reversal and Change of Policy Agenda • Draft RSSHIP bill was stopped at the point when it was ready for presentation the Rivers State House of assembly (State Parliament) - to be made into law • Emergence of New policy – Rivers State Social Services Trust Fund (health, education, water, sanitation and others) – to be funded through Social Services Levy • A new draft bill - Rivers State Social Services Levy Bill; was fast-tracked at through the State Parliament despite widespread public opposition (double taxation) • In the meantime, no progress has been made in implementing the new law since it became effective close to a year and half.

8. RSSHIP – Key Programme Elements • One universal health insurance programme for the entire population • Single risk pool - ‘Rivers State Health Insurance Fund’ to be managed by ‘Rivers State Health Insurance Agency’ • Premium contribution based on ability to pay • Formal sector contribution along NHIS lines – employer 10%, employee 5%, • premium subsidy (30 - 70%) for poor/informal sector, • premium exemption for vulnerable groups (but funded) • Comprehensive benefit package along NHIS lines • Mutual Health Associations as third-party administrators • Both public and private providers plus health promotion.

9. Social Services Trust Fund • Social Services Levy: 1% of Monthly salary, self-employed professionals - NGN25,000 ($167) pa, ?? Informal sector • SSTF to be applied in the following areas: • providing and improving on medical facilities in government health centres and hospitals; • providing free or subsidized medical care for indigenes in government health centres and hospitals; • funding free education in primary and secondary schools; funding scholarship in various disciplines in tertiary institutions; improving water facilities; • as well as support other essential social services that may be approved by the Executive Council (Rivers State Social Services Law, 2009)

10. Key Findings • Over-concentration of executive power in one person – State Governor, determines what policies get implemented in relation to other options • Commissioner of Health - supposedly chief health adviser, stand risk of losing his job if he presents a contrary alternative to that of the Governor • Despite rational planning process, strengthened by ‘political will’ shown by Governor himself (and ‘taken for granted’ by planners), it was too easy for Governor to over-turn an evolving policy and take a completely fresh path.

11. Key Findings II • Bureaucrats undertaking planning of RSSHIP, felt inadequate to advise the Governor on the merits and demerits of his new line of thinking – as no policy briefs were presented to him in this respect. • bureaucrats in spite of personal reservations were made to be part of development of new policy • They also failed to counter alleged plot to stop the RSSHIP in favour of the new policy • Little political analysis in identifying key actors; political resources available to them; their relative positions - support/opposition; public perception of the problem.

12. Key Lessons • Ultimately, policy making is political as well as technical - bureaucrats who posses neither of these skills in a specialised area such as this stand little chance of making things happen. • ‘Political will’ shown by Governor to advance social services remained, but was not properly channeled – as there was failure to understand the use of the right tools in public policy making. • Although the era of ‘health sector reforms’ as a development fad in international health development is gone, the ideas put forward by many proponents are still very valid.

13. Conclusion • In pursuing the goal of universal coverage in sub-Saharan Africa (SSA) many practitioners and policy makers are often much more concerned with the technical details of the various health financing mechanisms. But financing health care is a political matter as well. • And we should be prepared to deal with policy inconsistencies that often hinder progress.