kenneth ojo & paul angbazo partnership for transforming health systems 2 (paths2) abuja, nigeria
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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
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