Like many governments, Nigeria has struggled to meet its people’s growing healthcare demands. The country has been working towards universal healthcare since 2005 but its health indicators have stagnated or worsened during the past decade. Nigeria has 2% of the world population, but 14% of global maternal deaths. More than 12% of Nigerian children do not live to celebrate their fifth birthday, and 54% of Nigerians live in poverty.
The situation is even more alarming in rural areas. Kwara, one of the country’s poorest states, has remained largely off international donors’ radars and access to healthcare is extremely limited. Such factors motivated the Kwara State Government and local insurer Hygeia to enlist the support of Dutch partners to address this remote region’s immense healthcare challenges.
The Kwara State Health Insurance Programme is a public-private partnership (PPP) launched in 2007 and is now providing affordable and quality care for low-income people.
Nearly 80,000 people are now enrolled in the programme, most of them women and children. Kwara is the first Nigerian state government to fund a PPP to provide care for its citizens, covering 60% of their health insurance premiums in the programme driven by Hygeia, local politicians, religious leaders and communities. In March 2014, the State also committed to scale up the programme by 2018 to reach 60% of the rural population, or 600,000 people.
United Nations Secretary-General Ban Ki-moon has described this PPP as a groundbreaking, innovative hopeful example. “This unique initiative offers comprehensive healthcare to all people, year-round, at a modest cost. It is accomplished through co-operation among the Government, traditional rulers, the private sector and donors. This is exactly the kind of innovative partnership that we should replicate – here in Nigeria and beyond,” he said.
The Kwara State Health Insurance Programme is a viable financing alternative for providing inclusive healthcare on a long-term basis. It shares costs among PPP stakeholders including the state government, communities, public and private providers and health insurers, reducing individual risks while promoting efficiency, cost-effectiveness and innovation.
The multi-dimensional programme, set up with the support of the Dutch Ministry of Foreign Affairs, aims to help achieve the UN MDGs for health, addressing challenges on both demand and supply side of the health system.
Key actions for the demand side included focusing on low-income groups earning less than USD$1.50 per day in rural Kwara, subsidising health insurance to help them access affordable care. Patients’ partial payment of premiums promotes ownership and encourages them to demand quality care.
On the supply side, the SafeCare quality improvement programme was designed specifically for resource-restricted areas. SafeCare standards are approved by the International Society for Quality in Health Care and tailor-made for resource-poor settings. There has also been capacity building for healthcare providers and insurers on management, administration and performance-based contracting. Private sector involvement has boosted cost-effectiveness and innovation, with performance-based financing; data collection and impact evaluation have also been key to success.
A rigorous impact evaluation by an independent consortium of research organisations found that people with insurance have reduced out-of-pocket spending on healthcare by 52%, including the premium, while overall healthcare use has increased by 90%.
Dutch multinational companies Shell and Unilever have insured their Nigerian staff through Hygeia’s corporate program. The Investment Fund for Health in Africa, a private equity fund that forms a public-private partnership with the Health Insurance Fund, invested in Hygeia Nigeria Limited in 2007, followed by Dutch development bank, FMO, the International Finance Corporation, and Satya Capital.
Over the next five years, the Kwara State Government is allocating 34 million euros (US$42.5 million) to subsidise insurance premiums, improve the quality of 50 clinics per year and extend the programme across the state, eventually giving 600,000 rural low-income Nigerians access to quality healthcare. By 2017, the state will take full ownership of the scheme and intends to strengthen collaboration with donor-funded programs and to further develop its insurance programme as a replicable model, serving as a blueprint for other states in Nigeria. Ogun State launched a health insurance programme based on the Kwara model in April 2014 and approximately ten other states have shown interest in replicating the Kwara model, including the Lagos State, which has the city with the largest population in Africa, Lagos.
Professor Onyebuchi Chukwu, the Nigerian Federal Minister of Health, stated his government’s full support during the Presidential Summit on Universal Healthcare Coverage in March 2014, saying, “The results, in combination with the efforts of the Kwara state government, have created an effective channel to set the pace for other states interested in adopting this model of healthcare delivery, on the road to universal healthcare for all Nigerians.”
In 2014, the programme was recognised as a finalist in the OECD-DAC Prize for Taking Development Innovation to Scale and it also won the People’s Choice Award in the Saving Lives at Birth competition. And recent World Bank analysis into maternal and child care in Nigeria shows that since the programme started, Kwara has become the second best performing state in the country.
Ownership, political will, local leadership, motivation and trust among the parties involved have been key success factors for the programme.
Thus, it promotes the key element of the Busan Partnership for Effective Development Co-operation of partnerships that include the participation of all actors, recognising the diversity and complementarity of their different functions.
Building the business case for health insurance, insurers, administrators and healthcare providers requires considerable technical assistance to expand health coverage to lower income groups. Clear understanding is needed between partners about the mutual benefits, responsibilities and obligations as well as clarity on a partner’s starting level of capacity.
The concept of health insurance was new to the target population, and some people who did not fall ill during the year expected their money back, which may hamper re-enrollment. Similarly, healthcare providers who were used to receiving instant cash payments for health services have had to adjust these expectations and business practices. Building understanding around provider payment systems, and contracting and performance-based financing has required extensive training.
Despite challenges, use of higher quality healthcare providers doubled, and the health insurance proved cost-effective as per capita annual health expenditures reduced in the entire treatment area. The basic healthcare package annual plan costs US$28 per person, compared to US$68 for the Nigerian National Health Insurance Scheme standard package.
The Kwara programme has increased trust in the healthcare system and willingness to pre-pay for health insurance. By reducing risk and lowering transaction costs, the model has paved the way for private and public investments in medical, financial and administrative capacity. This has built faith in a previously dysfunctional health system, bringing one Nigerian state closer to universal health coverage.