Abuja — Okechukwu Ndaguba sits at a table in a noisy conference room at the Jades Hotel in Nigeria's capital city, summoning strength for the last day of a planning session about a new health insurance scheme.
Last week President Goodluck Ebele Jonathan signed into law a National Health Bill that greatly expands access to health care for Nigeria's 190 or so million people. The new legislation dedicates a portion of national revenues to primary health, expands the National Health Insurance Scheme (NHIS) to cover more people and provide a broader range of services, eliminates fees for pregnant women and children under five – as a way of reducing high rates of maternal and infant mortality – and expands emergency services
While NHIS already covers a major portion of the formal, employed sector, those covered number only about 4.5 million people. Implementers of the new law are therefore faced with the enormous challenge of coming up with ways of insuring those in the informal sector — consisting mostly of the unemployed and the urban and rural poor.
Ndaguba, who works for NHIS, believes that an emerging community-based model will make fulfilling the law's mandate possible. In addition, community schemes could provide a bulwark for Nigeria's crowded cities against the kind of epidemic emergency presented by Ebola.
Ndaguba's husky voice is freighted by weariness and skepticism, in common with many Nigerians tasked with making their large and complex country – the most populous in Africa – function better. But even the weight of his worries can't mask his excitement as he imagines the impact of the newly-launched Community Based Health Insurance (CBHI) programme. He hopes that the public-private model of extending health services, coupled with community engagement, will demonstrate ways that sustainable and affordable access to medical care could transform Nigeria's health landscape.
"The biggest attraction of community health insurance as a model for delivering universal health coverage is probably its inclusion of the community, the insurer, the provider and sometimes a third party in its management," says epidemiologist Chikwe Ihekweazu, who launched Nigeria Health Watch to provide informed commentary and analysis on the country's health sector. "Involving the 'people' is a principle that receives a lot of lip service but is rarely implemented."
Ihekweazu recently visited a community health insurance programme in Obio, Rivers State that he thinks has begun to deliver on that promise. He describes the scheme, which he calls "an island of hope", as a tripartite arrangement involving the state government, the Shell Petroleum company that operates in the area and the people – "a people/public/private partnership to deliver on health care".
In some ways, the community-based model resembles efforts to enable financial inclusion for the 'unbanked' – a proportion of the population that is around 75 percent across Africa. Bankers, in alliance with governments and community organizations, have created various products that allow millions of people without bank accounts access to the financial system for the first time.
Similarly, health-insurance practitioners in Nigeria have been looking for ways to create products that serve as points of entry into the nation's healthcare and health surveillance systems. For the plans to work, policymakers say, there should be products of varied design that enable access by a diversity of stakeholders – including both urban and rural communities.
No rural/urban split
The use of the term "community-based" purposely avoids the "rural" label, which is often assumed in discussions about expanding health services.
Health economist Dr. Kenneth Olayinka Ojo, who chairs the Center of Health Economics and Development, is one of the designers of the 'Ukana West 2' community-based insurance scheme in Akwa Ibom State, whose stakeholders are among those meeting at the Jades Hotel. Ojo bristles at the assumption that the new schemes are primarily for rural areas – and he eschews ways of thinking that draw a dichotomy between urban and rural in a country where those boundaries are blurred and so many people retain both identities.
"I don't want to look at 'community' as only for rural areas, no," says Ojo. "A community can be a bunch of urban elites or people who come from Ikoyi and come together in Ikoyi Club, as a community of rich people. (Ikoyi is an affluent area of Lagos, Nigeria's largest city and commercial center, and the club is an elite social and sports establishment.) Or an insurance association can be a "community of fishermen", he says, or a "community of Okada riders". (Okadas are commercial motorcycles that help fill a public-transport gap both within cities and between cities and surrounding areas.)
For Ojo, insurance is all about economies of scale. When people come together to define among themselves what kind of coverage they want for themselves and their dependents, they can drive community-based schemes – as long as they come together in sufficient numbers, take a common position and define a coverage package that is applicable to their situation.
Preventing the next Ebola
To appreciate the importance of having such community-enabled healthcare entry points, it is useful to look at the disaster that struck the largest cities of Guinea, Sierra Leone and Liberia this year.
Infectious disease specialists were able to trace the current Ebola epidemic back to its first patient – what epidemiologists call the 'sentinel case' – a two-year-old child in the Guinean village of Meliandou, in Guéckédou province in the far north-eastern corner of the country. The epidemic spiraled out of control, partly because it made its way to densely populated urban areas, where it had never been seen in previous epidemics, dating from 1976.
The earliest and hardest hit was in Liberia's capital of Monrovia, but it also spread to Guinea's capital and largest urban center, Conakry, as well as to Freetown, the capital of Sierra Leone. Why? One plausible reason is urbanization and modernization that have promoted the flow of people and goods from rural areas to cities.
In Liberia, the government of President Ellen Johnson Sirleaf had given priority to building good roads to promote commerce, to allow farmers to get crops to market, and to ease the path of citizens to schools and clinics. Afflicted Guineans in Guéckédou needed only to cross a small stream constituting the border between the two countries and make their way to a hospital in Kakata, midway to Liberia's capital, Monrovia. More than a dozen nurses and doctors in Kakata were early casualties of Ebola. From there, the improved road ran all the way to Monrovia, where the country's JFK Medical Center was quickly overwhelmed.
Pair a continuous rural/urban flow with a lack of community health structures that could have offered a network of disease surveillance, and the outcome was predictable.
In Nigeria, where Ebola cases stemmed from one case in Lagos and required extraordinary efforts to contain, the task of strengthening this country's health system has acquired a newly recognized urgency. The country has been declared Ebola free by the World Health Organization, but Nigerian health professionals say they must perform as well, or better, in the face of the next threat.
The ability for even poor Nigerians to get medical care when they are ill is an important safeguard against the next epidemic – whatever it may be. Delivering care to as many ill people as possible can offer health officials and epidemiologists more ways to know quickly when a threat appears. Early knowledge offers the chance to spread awareness about hygiene or facts about diseases, increasing the likelihood that a future outbreak can be contained and reduce the spread – either from rural to urban areas and vice versa or within vulnerable urban neighborhoods, which often have poor sanitation and low levels of prevention information.
A decade of learning
The Akwa Ibom State scheme being fine-tuned by the NHIS and other stakeholders launched in September. But the DNA of the new programme and others across the country dates to 2007, when a health investment fund backed by the Netherlands Ministry of Foreign Affairs partnered with the government of Kwara State.
Dr. Bukola Saraki, a physician, who is now a senator in Nigeria's federal parliament, was then Kwara governor. His wife, Toyin Saraki, enthusiastically supported the insurance plan – which she described in a 2007 forum organized by the Bill & Melinda Gates Foundation – as a powerful way to reduce deaths of mothers and babies during pregnancy and childbirth. The Wellbeing Foundation she launched in 2003 to support improved health outcomes in Kwara has become a national philanthropy promoting that cause, as well as other health advances.
Within a year, Kwara's Community Health Care program had opened 10 clinics, and the scheme has continued to expand. Adult enrollees were charged two dollars per person per year, with a family plan to cover children. A June 2013 report by the Brookings Institution, cited Kwara's program as an "innovative model" that can and should be replicated in other states and across Nigeria.
Those minimal 'membership' fees provided an income stream for salaries, drugs and electricity, but Kwara's government and other partners subsidized about 93 percent of the operating costs. Clinic health staff told a visiting reporting team from AllAfrica that even the small sums paid by members gave them a sense of ownership. They felt empowered to demand accountability from providers, which raised the standard of care.
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Proof that community-based programmes still empower local communities can be heard loud and clear back at the conference in Abuja. Ukana stakeholders at the Jade hotel include health insurance experts, primary health care workers from local governments, village development community heads, youth and women leaders, the Akwa Ibom health ministry's director of planning and statistics, Dr. Emmanuel Boniface Ekong, and Michael Akpabio, who chairs the Board of Trustees overseeing the program. Funmi Esan, with over 16 years of experience in delivering sustainable community development programs, coordinates the lively discussions with the deft touch of a center midfielder or quarterback.
On the sidelines, speaking over the noise in the room, Trustee Akpabio explains that trustees provide "the bridge between the [healthcare] service providers and the people who need the service. To register the numbers of people targeted, officials must help rid the people of skepticism about the government, explained Trustee Akpabio, whose short Afro and beard, peppered with white streaks, gives him the air of an avuncular professor as he explains complex structures and the choices being made.
The Akwa Ibom plan charges higher fees – about U.S.80 annually for a family of six – than the Kwara programme. Data being collected from the numerous community insurance schemes taking shape across the country will help planners determine what models are most effectible and sustainable.
Everyday sees the dramatic movement of people from Nigeria's rural to urban areas, where there are more economic opportunities. According to UN-Habitat, Africa will have more than 300 million new urban dwellers by 2030 – more than half of the continent's poor. Building resilient health systems to absorb future shocks must take account of the circular migration of people who move back and forth between rural and urban areas.
"There is a lot to learn," says epidemiologist Ihekweazu. "I was told about how the gardeners in Obio had formed themselves into a choir to sing as they worked, and I smiled about the spirit of Nigerians when it is let loose," he says. "One day, we will sing as these gardeners when our country begins to achieve its full potential; but in the meantime there is much work to be done."
Reporting on African cities and their efforts to build resilience is supported by the Rockefeller Foundation.
