Kenneth Ojo & Paul Angbazo
Partnership for Transforming Health Systems 2 (PATHS2)
Abuja, Nigeria
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The need to address the challenges of health care financing
for universal financial protection in Nigeria,
The current scheme in Nigeria started with a mandatory
health insurance for the federal civil service through
National Health Insurance Scheme
Overall coverage is about 3% of the Nigerian population
It is therefore apparent that there is a need to provide
sufficient financial risk protection to the rest of the
uncovered population against the cost of health care.
Governments at all levels already identified the need to
support the scaling-up of risk pooling mechanisms in the
health sector and the development and expansion of
community based health insurance to achieve universal
coverage.
There is need generate evidence for decisions on scaling up
1)
2)
3)
Inventory study of CBHIS and other Social
Solidarity Groups by NHIS
Development of some schemes by some
states governments – Lagos, Kano, others
Communities and Private Sector Initiatives
in the establishments of some schemes
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Economic framework focusing on willingness-topay, information, price and quality
Health system framework: institutional context of
the health system, analyzing interactions between
insured, insurance schemes, health service
providers and the government
Are these necessary and sufficient conditions for
scaling up and sustainability of the CBHI schemes?
What can we learn from the social
framework/determinants or a combination of the
three in understanding the essential factors for
scaling up and sustainability of the CBHI schemes ?
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Can Economic theory take into account contextdependent policy considerations through the theory of
Social Capital?
Can Willingness to pay be increased by solidarity bonds
and should be purely understood in neoclassical economic
terms, where willingness to pay is based on individual
expected utility?
Can the complex interplay between rational utility
maximizing and socio-cultural norms (such as solidarity,
collective action) probably affects individuals’ decisions to
join a scheme?
Can we argue with evidence that social capital facilitates
collective action and willingness to pay?
What should be the role of government in widespread
coverage through CBHIS?
Social capital – a measure of how much people within a society
are willing and able to help each other – is regarded as an
important determinant of individuals’ willingness to pay for CBHI
(along with expected economic and quality gains);
 Willingness to pay in turn is a key determinant of whether or not a
CBHI scheme is feasible and sustainable.
 Social capital can be operationalized in four dimensions: inter and
i.
links within communities/ inter-community bonding social
capital
ii. links between communities/ intra-community bonding social
capital
iii. links between different institutions/ Micro level bridging
social capital: vertical and horizontal civil society links and
iv. links between governments and their citizens/ Macro level
bridging social capital
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Specific Objectives:
 Identify the numbers, size, characteristics of all
existing CBHIS and other social solidarity
organizations with similar characteristics with
the CBHIS and examine the potentials and policy
implications for transforming them into viable
CBHI schemes
 Identify other civil society groups, who could play
roles in the mobilization and sensitization of
communities for CBHIS.
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This study covers all the existing CBHIS in terms of
mapping and detail analysis in all the six zones of
Nigeria.
Mapping all the identifiable CSOs in the each zone
and sampled for detail analysis 25 CSOs (where there
are more than 25 and all where the CSOs are less than
25)) in each Local Government Area (LGA).
Stratified sampling covering all the 8 categories of
CSOs :group one has Cooperatives societies, Trade
unions and Artisans and group two has Gender based
NGOs ,CBOs, CDAs and Foundations
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International Non-governmental Organizations (NGO)
Non-governmental Organizations (NGO) – national- Broader
focus and target audience; more structured; registered
Faith-based Organizations (FBO) - Religious affiliation; more
structured; registered
Community-based Organizations (CBO)- Community-based and
focused; some structure; some registration
Community Development Associations (CDA)
Social Solidarity Groups
Alumni Associations; Friends’ Clubs; Community Associations
meeting outside the community; etc
Cooperative Societies
Professional Associations – Accountants, nurses, doctors, etc
Trade Unions
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Social and economic context
Management and organization structure
Core focus of the group; aims and objectives
Membership- size, types, composition and
coverage
Health Benefit package in the scheme
Health care provision issues-drugs, human
resources, facilities, quality of services
Provider payment mechanism
Financial management, accounting and control
Contribution mechanism
Size of funds available
Investment capacity
Supervision, monitoring and evaluation
Promotion and marketing the scheme
Role of government and other regulators
Risk management issues- adverse selection,
moral hazard, fraud, cost escalation
• Equity issues
• Sustainability issues
• Challenges faced by the scheme
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Autonomy
Not for profit
Solidarity
Democratic decision making and
accountability
Risk sharing
Responsibility
Social movement
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Civil Society Organizations (CSOs) are nongovernmental,
not-for-profit,
voluntary
organizations formed by people within the social
sphere of the society
They cover a variety of organizational interests and
forms, ranging from formal organizations
registered with authorities to informal social
movements coming together around a common
cause
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Non-governmental
Voluntary
Non-political
Not-for-profit
Common focus
Target Audience
Benefit of others
Non-religious (except FBOs)
Membership-based (not all)
4000
3500
3000
2500
2000
1500
1000
500
0
Cooperative
Trade
Artisan
Prof.
Association
FBO
Categories
Gender
NGO/
CDA
Foundation
2000
1800
1600
1400
Number of CSO
1200
1000
800
600
400
200
0
EKITI
LAGOS
OGUN
ONDO
OSUN
OYO
Cooperative Societies
60
895
162
21
1843
369
Artisan
193
85
1
76
91
240
CDA
132
0
20
188
1475
948
Categories of CSOs
350
300
250
Individual
Group
200
Government
Community
150
Traditional
Insitution
100
Others
50
0
Cooperative
Societies
Trade Union
Artisan
Association
FBOs
Gender Based
NGOs CBOs
CDA
Foundation
600
500
400
300
200
100
0
0-5 years
6-10 years
11-25 years
26-50 years
50 years above
States by Working on Women Issues
350
300
250
200
150
100
50
0
EKITI
LAGOS
OGUN
ONDO
OSUN
OYO
Yes
18
34
36
51
154
180
No
79
145
85
97
307
309
States by Working on Social Issues
400
350
300
250
200
150
100
50
0
EKITI
LAGOS
OGUN
ONDO
OSUN
OYO
Yes
74
139
86
115
312
379
No
25
40
36
33
150
111
Categories of CSOs by Poverty Eradication /Granting of Loans/ Revenue generation
250
200
150
100
50
0
Cooperative
Societies
Trade Union
Artisan
Association
FBOs
Gender Based
NGOs CBOs
CDA
Foundation
Yes
233
78
44
11
14
30
55
6
No
152
166
161
51
45
126
207
18
Categories of CSOs by Members Welfare/Improve Standard of Living/ Improve Members
300
250
200
150
100
50
0
Cooperative
Societies
Trade Union
Artisan
Association
FBOs
Gender Based
NGOs CBOs
CDA
Foundation
Yes
271
194
165
30
34
88
86
12
No
115
51
40
32
25
68
176
12
Categories of CSOs by Membership Contribution
450
400
350
300
250
200
150
100
50
0
Cooperative
Societies
Trade Union
Artisan
Association
FBOs
Gender Based
NGOs CBOs
CDA
Foundation
Yes
405
255
230
56
51
129
271
13
No
14
13
6
15
10
41
9
10
Categories of CSOs by Donations
300
250
200
150
100
50
0
Cooperative
Societies
Trade Union
Artisan
Association
FBOs
Gender Based
NGOs CBOs
CDA
Foundation
Yes
157
133
110
57
38
119
162
18
No
262
135
126
14
22
51
117
4
Categories of CSOs by Individual
350
300
250
200
150
100
50
0
Cooperative
Societies
Trade Union
Artisan
Association
FBOs
Gender Based
NGOs CBOs
CDA
Foundation
Yes
308
207
199
55
54
147
211
18
No
110
63
38
14
7
24
68
3
Categories of CSOs by Group
250
200
150
100
50
0
Cooperative
Societies
Trade Union
Artisan
Association
FBOs
Gender Based
NGOs CBOs
CDA
Foundation
Yes
182
124
93
38
26
65
133
6
No
236
145
144
32
35
106
145
15
Categories of CSOs by Is Membership Voluntary or Compulsory?
450
400
350
300
250
200
150
100
50
0
Cooperative
Societies
Trade Union
Artisan
Association
FBOs
Gender Based
NGOs CBOs
CDA
Foundation
Voluntary
391
171
98
63
56
161
233
20
Compulsory
27
98
140
7
6
10
44
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 Stewardship :regulation & monitoring;
 Creating an enabling environment:
rule of law, advocacy, information
sharing,
aid
communities
in
constructing social capital to create
better conditions for CBHI
Resource transfer: subsidies,
incentives, facilities etc
Did the Government have any Role in the Establishment
300
250
200
150
100
50
0
Cooperative
Societies
Trade Union
Artisan
Association
FBOs
Gender Based
NGOs CBOs
CDA
Foundation
Yes
250
123
81
25
25
50
160
4
No
168
145
156
45
37
121
119
16
Does the Government Povide any Support to your Organization
250
200
150
100
50
0
Cooperative
Societies
Trade Union
Artisan
Association
FBOs
Gender Based
NGOs CBOs
CDA
Foundation
Yes
222
105
52
24
22
48
165
3
No
82
66
103
20
16
41
42
6
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Evidences generated suggest that four categories of
organizations, namely, Cooperative societies, Community
Development Associations, Trade unions, and Artisans
organizations are adaptable for participation in CBHIS .
Two categories of organizations; Community Based
Organizations and Gender Based organizations would be useful
partners in community mobilization and sensitization.
NGOs and Foundations may be useful partners for mobilization
and technical support.
The need to develop appropriate advocacy and communication
strategy to engage with these organizations
Government roles should be clearly defined