Community-based health insurance programmes and the national health insurance scheme of Nigeria: challenges to uptake and integration

Searches of PubMed and EconLit were undertaken using the search string (Community-based health insurance OR Community health insurance) AND (Nigeria OR Ghana OR developing countries OR Senegal OR Rwanda OR Cameroon OR Africa OR Uganda OR Kenya OR Tanzania OR Guinea) NOT India. Criteria for inclusion were that papers should report analyses of CBHI uptake and policy implications that were informative in identifying barriers to enrolment and sustainability. Meta-analyses and authoritative reviews on the subject were also included. Other relevant sources that were utilised for key demographic, health and economic data included principally websites of organisations such as the World Health Organization (WHO), official government NHIS websites of countries of interest, the World Bank and the Center for Health Market Innovations.

Although papers detailing research in Asian countries were not included in the main analysis, points of interest from the Asian experience of CBHI that became apparent during the literature review are briefly covered in the discussion to increase the generalisability of the findings.

Papers were selected with the assistance of an independent expert (JN). We accepted literature that dealt specifically with CBHI schemes based on the model of voluntary participation and the concept of risk pooling, and that set out to analyse factors contributing to recruitment and retention. We also included relevant reviews and discussion papers, and official or policy documents that dealt with reasons for and potential solutions to difficulties with CBHI enrolment. To aid with selection, papers were tabulated in a spreadsheet and ordered by country and classified as studies, reviews or other. After sorting and obtaining full copies of the papers selected, we examined each publication for information on factors relevant to the success or otherwise of CBHI schemes, with particular emphasis on observations recurring across different countries. Positive and negative contributors to successful CBHI implementation that had been identified were then tabulated with a listing of countries where these factors had been noted. The observations were used to formulate recommendations for policy decisions with the potential to improve uptake in Nigeria and other countries where progress with CBHI has been poor.

Factors driving the success or failure of CBHI schemes appear as recurring themes in Nigeria and other SSA countries (Table 2). Problems are chiefly operational in nature and include failure to account for the inability of the target population to pay for scheme membership, lack of clear legislative and regulatory frameworks coupled with inadequate financial support, and unrealistic enrolment requirements. The last is linked to failure on the part of administrators to align ‘real-world’ socioeconomic conditions with those suggested by theoretical models, to account for the target population’s willingness to pay for a scheme, and to engage communities in decision making from the earliest stages. Failure to engage beneficiary participation in CBHI, lack of comprehensive cover and failure to appoint an omnibus regulator have all been criticised [7]. Moreover, patient preferences may not be receiving sufficient attention, and packages suitable for one community may not suit another [24]. These issues recur across countries that have faced significant difficulties in implementing CBHI. Problems with quality of service and a lack of trust in the integrity of the schemes and their administrators and providers have also been identified, particularly in Uganda, Guinea and Burkina Faso (Table 2). Lack of awareness also continues to present barriers to enrolment [7, 23]: 97% of a sample of rural Nigerian surgical patients in one survey had no knowledge of their government’s insurance Schemes [22]. Most had paid for their treatment from personal savings or had relied on family members. In Senegal, Moslems were found in the early 2000s to be much less likely than Christians to enrol because they mistakenly believed that the schemes were open to Christians only [27].

Conversely, success factors are also evident. Researchers in Cameroon and Nigeria have documented a clear desire on the part of less well-off households to join schemes (Table 2), and over 3000 Nigerian survey respondents stated that CBHI was an acceptable means of paying for health regardless of socioeconomic background or location [26]. Interestingly, the poorest households expressed the greatest willingness to enrol. Countries such as Ghana and Rwanda have shown key drivers of success to include uniform and comprehensive benefit packages, adequate finance by government and elimination or minimisation of copayments. Flat-rate payments are likely to discourage the very poor [9, 25], and the use of funds from taxation has been shown to be necessary to avoid the need for regressive member contributions. Even in a relatively successful country such as Senegal, there has been difficulty in reaching the very poorest members of society, which has highlighted the need for subsidies [27]. Targeted subsidies for the most disadvantaged have a positive influence as long as adverse selection is avoided [21, 23] (Table 2).

Providing a specific focus for CBHI (e.g. maternity services [21]) has been shown to assist adequate funding and improve coverage in rural communities. Other initiatives of this kind include the Hygeia Community Health Plan (Lagos and Kwara State, Nigeria) that aims to improve access to cardiovascular care in low-resource settings [41].