Universal Coverage: Reflections of a
missed opportunity in Rivers State,
Nigeria
Tarry Asoka – 2nd Conference of
African Health Economics and Policy
Association (AfHEA) 15th – 17th 2011,
Palm Beach Hotel, Saly, Senegal
Introduction
• Universal access to health care will improve health
outcomes in SSA
• Adoption of social health protection mechanisms is
a fundamental step (WHO, 2008)
• Method of achieving this is irrelevant as long as
people are protected from financial risk of ill health
• In Rivers State, Nigeria – a planned social health
insurance model aimed at universal coverage was
set aside for social services trust fund
• What went wrong? What measures should have
been taken to safeguard the programme?
Methodology
• A single case study – Rivers State Health insurance
Programme (RSSHIP)
• Narrative inquiry - to make sense of the relationship
between human actions and the social context in
which they have occurred.
• Main sources of data - a personal account of the
author who provided technical assistance and
guidance to the programme from inception, as well
as documents (reports, minutes of meetings,
programme memorandum, draft law etc) that were
produced in the planning process.
• Additional feedback from the main actors
Case Report – Rivers State Health
Insurance Programme (RSSHIP)
The Background Context – Political economy and
Institutional Analysis
• Rivers State (pop.5.1m) - one of 36 States in Nigeria
that has considerable resources and autonomy
• State capital, Port Harcourt – centre of oil & gas, 3rd
major business city after Lagos & Abuja
• State was at the center of an intense struggle for
supremacy among competing political interests
• Emergence of a new Governor in October 2007
following a landmark Supreme Court judgment was
seen as a new opportunity to provide better
governance through a process of rational planning
Case Report – RSSHIP II
Conceiving and Developing a Social Health Insurance
Programme
• Health Summit - Governor outlined his expectations
from the conference and also agreed to implement
recommendations as coming from the people.
• A major recommendation from the Health Summit establishment of a ‘Health Fund’ to finance health
care in the State on a sustainable basis
• Rivers State Health Policy & Health Financing
Conference – proposed the establishment of RSSHIP
Case Report – RSSHIP III
• Study tour of the country to consult with relevant
institutions, as well as field visits to similar schemes
• Executive memo approved by State executive
Council
• Commissioner of Health set up a technical
committee to design the programme
• Technical committee – programme memorandum,
draft bill, and plan of action for implementation
• Draft bill reviewed by legislative drafting unit of
Ministry of Justice
Case Report – RSSHIP IV
Reversal and Change of Policy Agenda
• Draft RSSHIP bill was stopped at the point when it was
ready for presentation the Rivers State House of assembly
(State Parliament) - to be made into law
• Emergence of New policy – Rivers State Social Services
Trust Fund (health, education, water, sanitation and others)
– to be funded through Social Services Levy
• A new draft bill - Rivers State Social Services Levy Bill; was
fast-tracked at through the State Parliament despite
widespread public opposition (double taxation)
• In the meantime, no progress has been made in
implementing the new law since it became effective close
to a year and half.
RSSHIP – Key Programme Elements
• One universal health insurance programme for the entire
population
• Single risk pool - ‘Rivers State Health Insurance Fund’ to be
managed by ‘Rivers State Health Insurance Agency’
• Premium contribution based on ability to pay
o Formal sector contribution along NHIS lines – employer
10%, employee 5%,
o premium subsidy (30 - 70%) for poor/informal sector,
o premium exemption for vulnerable groups (but funded)
• Comprehensive benefit package along NHIS lines
• Mutual Health Associations as third-party administrators
• Both public and private providers plus health promotion.
Social Services Trust Fund
• Social Services Levy: 1% of Monthly salary, self-employed
professionals - NGN25,000 ($167) pa, ?? Informal sector
• SSTF to be applied in the following areas:
o providing and improving on medical facilities in
government health centres and hospitals;
o providing free or subsidized medical care for indigenes in
government health centres and hospitals;
o funding free education in primary and secondary schools;
funding scholarship in various disciplines in tertiary
institutions; improving water facilities;
o as well as support other essential social services that may
be approved by the Executive Council (Rivers State Social
Services Law, 2009)
Key Findings
• Over-concentration of executive power in one
person – State Governor, determines what policies
get implemented in relation to other options
• Commissioner of Health - supposedly chief health
adviser, stand risk of losing his job if he presents a
contrary alternative to that of the Governor
• Despite rational planning process, strengthened by
‘political will’ shown by Governor himself (and
‘taken for granted’ by planners), it was too easy for
Governor to over-turn an evolving policy and take a
completely fresh path.
Key Findings II
• Bureaucrats undertaking planning of RSSHIP, felt
inadequate to advise the Governor on the merits
and demerits of his new line of thinking – as no
policy briefs were presented to him in this respect.
• bureaucrats in spite of personal reservations were
made to be part of development of new policy
• They also failed to counter alleged plot to stop the
RSSHIP in favour of the new policy
• Little political analysis in identifying key actors;
political resources available to them; their relative
positions - support/opposition; public perception of
the problem.
Key Lessons
• Ultimately, policy making is political as well as
technical - bureaucrats who posses neither of these
skills in a specialised area such as this stand little
chance of making things happen.
• ‘Political will’ shown by Governor to advance social
services remained, but was not properly channeled
– as there was failure to understand the use of the
right tools in public policy making.
• Although the era of ‘health sector reforms’ as a
development fad in international health
development is gone, the ideas put forward by
many proponents are still very valid.
Conclusion
• In pursuing the goal of universal coverage in subSaharan Africa (SSA) many practitioners and policy
makers are often much more concerned with the
technical details of the various health financing
mechanisms. But financing health care is a political
matter as well.
• And we should be prepared to deal with policy
inconsistencies that often hinder progress.