Kenneth Ojo & Paul Angbazo Partnership for Transforming Health Systems 2 (PATHS2 )

1. Kenneth Ojo & Paul Angbazo Partnership for Transforming Health Systems 2 (PATHS2) Abuja, Nigeria Scaling up Community Based Health Insurance Scheme: Nigerian Experience towards Universal CoveragePresentation at African Health Economic and Policy Association ConferenceSaly, Senegal 15th– 17th March, 2011

2. 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

3. Current efforts at scaling up • Inventory study of CBHIS and other Social Solidarity Groups by NHIS • Development of some schemes by some states governments – Lagos, Kano, others • Communities and Private Sector Initiatives in the establishments of some schemes

4. 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 ?

5. 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?

6. 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 and • links within communities/ inter-community bonding social capital • links between communities/ intra-community bonding social capital • links between different institutions/ Micro level bridging social capital: vertical and horizontal civil society links and • links between governments and their citizens/ Macro level bridging social capital

7. 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.

8. 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

9. 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

10. 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

11. 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

12. BASIC PRINCIPLES OF COMMUNITY BASED HEALTH INSURANCE • Autonomy • Not for profit • Solidarity • Democratic decision making and accountability • Risk sharing • Responsibility • Social movement

13. 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

14. 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)

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

16. Number of CSOs Identified by Categories

17. CATEGORIES BY WHO INITIATED THE ORGANIZATION

18. Years of Existence of Organizations

19. AREAS OF WORK OF ORGANIZATION BY STATE

20. AREAS OF WORK OF ORGANIZATION BY STATE 2

21. CATEGORIES BY OBJECTIVES

22. CATEGORIES BY OBJECTIVES 2

23. SOURCE OF INCOME BY DIFFERENT CATEGORIES OF CSOs

24. SOURCE OF INCOME BY DIFFERENT CATEGORIES OF CSOs 2

25. TYPE OF MEMBERSHIP BY CATEGORIES OF CSOs

26. TYPE OF MEMBERSHIP BY CATEGORIES OF CSOs 2

27. CATEGORIES OF CSOs BY MEMBERSHIP TYPE

28. 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 CBHI • Resource transfer: subsidies, incentives, facilities etc

29. ROLE OF GOVERNMENT IN THE ESTABLISHMENT BY CATEGORIES OF CSOs

30. SUPPORT BY GOVERNMENT TO DIFFERENT CATEGORIES OF CSOs

31. 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