Monday, 7 March 2011

Goddy Leye | The Birth of Contemporary African Art

I watched this film and was moved to tears. It is how so many artists in Africa really feel about being artists. The work is courageous, brave, ambitious and true. Here is a wonderful tribute to a fallen hero.

Saturday, 5 March 2011

Initative Health Insurance Programme in Nigeria

(Possible Health Insurance

Programme for Artists of Africa)

A Dutch-supported foundation is 'exporting' private health
insurance to Nigeria, selling a US$ 30 health-care package
for US$3. Gary Humpherys reports.

In Kwara state, a poor agricultural district in western 
Nigeria, health insurance is a rarity. Like 70% of Nigerians, 
most people survive on less than one dollar a day. If they 
visit the doctor at all, they have to pay out of their own 
pockets. However, this grim situation recently changed 
for one group of farmers.
They are not covered by Nigeria’s National Health Insurance 
Scheme (NHIS), which despite being set up more than a 
decade ago, still only serves 3.73% of the population (civil 
servants working for the Federal government and in Bauchi 
and Cross River states, and 300 000 women and children 
under the Maternal and Child Health Project). Nor are they 
one of the seven million or so Nigerians, of a total population 
of 148 million, who can afford to pay for private health 
insurance. The 35 000 farmers and their dependents are 
in fact the beneficiaries of a scheme put together by 
PharmAccess, a Dutch government-backed, not-for-profit 
organization that supports HIV/AIDS treatment and what 
it describes as “general health-care projects” in developing 
In Nigeria, PharmAccess is supporting the idea of private 
health insurance, which it is delivering through the Health 
Insurance Fund (HIF), a foundation set up to pilot low-cost 
private health insurance, which includes HIV/AIDS care and 
treatment for low- to medium-income groups in sub-Saharan 
HIF includes among its backers The World Bank and the 
United States Agency for International Development (USAID) 
– institutions that take an interest in applying private health 
insurance ‘solutions’ to health financing problems in 
developing countries. The Dutch also have a strong 
commitment to private health insurance in their national 
system. So in a sense they are ‘exporting’ their know-how. 
HIF’s local partner is Hygeia, a health management 
organization (HMO). Hygeia is one of Nigeria’s largest HMOs 
with a network of more than 250 clinics and hospitals.
On the face of it the HIF scheme is puzzling. After all, how 
can people earning less than a dollar a day pay for the kind 
of insurance that would give them access to, for example, comprehensive maternal health care? The answer is they 
Establishing precisely how much they could or would pay 
was one of the research goals set by Emma Coles, HIF’s 
director. “There really is no data on this,” she says. “So 
we look at peoples’ income. We also look at what they are 
already spending out of pocket, which roughly matches 
what they are willing to pay.”
According to World Health Organization statistics, total 
health expenditure in Nigeria is around US$ 33 per capita, 
63.4% of which comes directly out of pocket. This suggests 
that the farmers of Kwara state might be ready to spend 
around US$ 20 annually – or slightly less given the poverty 
of the region.
In fact, the farmers were reluctant to pay anything like 
this amount. Indeed, since 2007, Hygeia has been offering 
the farmers a health-care package comprising comprehensive 
primary health care and limited secondary health care, 
including up to five days of hospitalization, and maternal 
health care (including caesarian section) – a health-care 
package that HIF prices at US$ 30 a year – for slightly less 
than US$ 3.

So who pays the US$ 27 balance? According to Coles, HIF is 
picking up the tab for the time being. Needless to say, this 
raises questions about the applicability of the term ‘private 
health insurance’ in this case, and also highlights sustainability 
issues. According to Coles, one solution for sustainability is 
the support of the Kwara state government. “The state 
governor has refurbished three public hospitals within the
scheme, has committed to co-finance its expansion of the
scheme and will take over the subsidies over a five-year
period,” she explains, pointing out that this is a matter of
contractual commitment by state governor Dr Abubakar
Bukola Saraki.
Whether that contractual commitment will ultimately be 
honoured is questioned by some. Dr Tolu Ayangbayi, a health economist formerly with the Nigerian Ministry of Health, for 
example, says, “In five years’ time, the person who promised 
[to pay the subsidy] today will not be in the government. 
So who are you going to hold accountable?”
Coles is also hopeful that consumers will start paying more 
of the premium as they begin to appreciate the advantages 
of prepayment and see what they are getting for their money. 
According to Dr Abayomi Sule, programme coordinator of the 
Hygeia Community Health Plan in Nigeria, attitudes are 
already changing. “Initially people did not understand the 
prepayment concept but over time we have educated them,”
he says. “We say it is a community scheme. If they don’t
use it, their neighbour will.”
According to Dr Peju Adenusi, chief executive officer of the 
Hygeia Community Health Plan, the farmers have been 
delighted with what they get for their money. “Utilization in
one clinic has jumped from 16 people per month before the programme was started to 1500 people per month
afterwards,” she says. One woman was so grateful for the
life-saving Caesarean section she received that she named
her baby boy Hygeia.
To be fair to HIF, it needs to be pointed out that, just because 
people are not paying a lot for the care they receive, does 
not mean that quality shouldn't be rewarded. After all, the
farmers can choose which clinic or hospital they walk into
and, although they are only paying $3 dollars, the clinic or
hospital then bills Hygeia for the care dispensed. Theoretically
at least, this provides an incentive to give quality service.
According to Coles, PharmaAccess has seen a substantial
increase in the quality of the clinics which it measures
every six months.
However, it is questionable whether such demand-side 
stimulus changes much in the context of Kwara state, 
where, according to Adenusi, a handful of clinics and three
hospitals serve a population of around three million people.
Moreover, as pointed out by Adenusi herself, the Hygeia
Community Health Plan operates as a monopoly in Kwara
state. The farmers don’t really have much choice.

They are not alone in this. Despite there being 42 HMOs 
in Nigeria, consumer choice is generally left out of the 
equation. “Part of the problem in Nigeria is that HMOs tend 
to be granted a state monopoly as part of a contract with 
NHIS,” explains Dele Abegunde, a Nigerian health 
economist working with WHO’s Essential Medicines and 
Pharmaceutical Policy Department. “There’s a kind of 
free market approach inherent in the NHIS choice for 
managed care insurance approach but, because of 
peculiarities on the ground, the principles of competition 
are not applied and the benefits elude the consumers,” 
he says. Abegunde also points out that many Nigerian 
HMOs typically rake 15% off the top. This attracts a lot 
of players, including financial institutions such as banks, 
which have neither the skills, professional mandate nor 
training for operating managed care.
Neither PharmAccess nor HIF make any claim to solving 
Nigeria’s health financing problems, but they do hold out 
the hope of incremental improvement by addressing 
what is arguably Nigeria’s biggest health financing 
challenge – the extension of health insurance coverage 
to nongovernment workers. Abegunde estimates that 
around 90% of the total workforce is engaged in informal 
employment of this kind – whether in casual or freelance 
work or agricultural labour. Not visible on payrolls or tax 
returns, nongovernment workers are notoriously difficult 
to ‘capture’ in insurance schemes which are generally 
based on documentation of one kind or another.
HIF offers a way into the informal sector by targeting 
specific groups for coverage. It doesn’t really matter 
what the group is as long as it can be readily identified. 
Cole explains: “If the insurance isn’t offered to identifiable 
groups that can share health risks, you run the risk of 
adverse selection.” In other words, the service offered 
would be overwhelmed by the sick and elderly, while the 
healthy and young would tend to stay away.
In the United Republic of Tanzania, where HIF has just 
launched a second pilot programme, it is working with 
people with micro-loans from a local financial organization 
and is also developing a programme for coffee farmers 
in the Kilimanjaro region. The approach makes sense 
within the terms of what HIF is trying to achieve but, 
from a broader health policy perspective, it leaves key 
challenges unmet. What happens to all the people who 
can’t be easily grouped, for example?
No-one is going to blame HIF for excluding people from 
what is, after all, a pilot scheme, but there are issues 
with this kind of targeted approach nevertheless. For 
Abegunde, the problem is that ultimately the whole 
population needs help and thus excluding anyone, no 
matter what the reason, should not occur. “We need 
national policy and national oversight,” he says. “We 
need solutions that work for the population as a whole.”
For Ayangbayi the problem of targeting is compounded 
when virtually all of the funding comes from outside. 
“You’re giving the Kwara state government a five-year 
break from their responsibilities – from what they ought 
to be doing themselves,” he says.

Source: World Health Organisation