(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$3. Gary Humpherys reports.
In Kwara state, a poor agricultural district in western
Nigeria, health insurance is a rarity. Like 70% of Nigerians,
most people survive on less than one dollar a day. If they
visit the doctor at all, they have to pay out of their own
pockets. However, this grim situation recently changed
for one group of farmers.
insurance to Nigeria, selling a US$ 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
countries.
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
countries.
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
Africa.
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
Africa.
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.
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
don’t.
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
don’t.
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.”
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.
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.
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.
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?”
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.”
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.
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.
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.
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.
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.
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.
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?
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.”
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
http://www.who.int/bulletin/volumes/88/5/10-030510/en/index.html
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
http://www.who.int/bulletin/volumes/88/5/10-030510/en/index.html
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