Universal Coverage: Reflections of a missed opportunity in Rivers State, Nigeria

1
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

2
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?

3
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

4
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

5
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

6
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

7
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.

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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
• Formal sector contribution along NHIS lines
  employer 10, employee 5,
• premium subsidy (30 - 70) for poor/informal
  sector,
• 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.

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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
• providing and improving on medical facilities in
  government health centres and hospitals
• providing free or subsidized medical care for
  indigenes in government health centres and
  hospitals
• funding free education in primary and secondary
  schools funding scholarship in various
  disciplines in tertiary institutions improving
  water facilities
• as well as support other essential social
  services that may be approved by the Executive
  Council (Rivers State Social Services Law, 2009)

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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.

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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.

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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.

13
Conclusion

• In pursuing the goal of universal coverage in
  sub-Saharan 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.