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COMMUNITY BASED HEALTH INSURANCE (CBHI) IN NIGERIA: PROSPECTS AND CHALLENGES.

ByVictor Eyo Assi

Department of Sociology & AnthropologyUniversity of Uyo, Uyo Akwa Ibom state.Email: victorassi82@gmail.com

Tel: 08037719495&

Dorothy Ononokpono (PhD)Department of Sociology & AnthropologyUniversity of Uyo, Uyo Akwa Ibom state.

Email: doraon5@yahoo.comTel: 08104277552

ABSTRACTOne of the mechanisms for securing financial protection and achieving universal health coverage (UHC) was identified as risk pooling, using health insurance principles to help prevent catastrophic health expenditure by families. Failure to achieve UHC in developing countries including Nigeria has left majority of the population without access to basic health services. Community-based health insurance (CBHI) is currently advocated as a viable strategy to achieve sustainable Universal Health coverage. CBHI initiatives are growing rapidly in developing countries. For instance in Asia, it was estimated that over 7.5 million Indians benefit from about 40 CBHI programmes. The uptake of CBHI in Sub-Saharan African countries remains poor, with the exception of Ghana and Rwanda both of which have introduced the schemes with effective government control and support. The success of CBHI programmes in these countries, suggests that CBHI can be a feasible option for different contexts. CBHI schemes vary a great deal in terms of who they cover, how they cover, for what, and at what cost. Few Community-Based Health Insurance (CBHI) programmes have been implemented in some states of Nigeria but without much success. Health care in Nigeria is financed by a combination of tax revenue, out – of pocket payments, donor funding, and National health insurance scheme. Nigeria's health expenditure is relatively low, even when compared with other African countries. Thus considering the need to achieve the sustainable development goal (SDG) which seeks to ensure healthy lives and promote well-being for all at all ages, it is important to examine the feasibility of CBHI programme in a country like Nigeria where the health care system remains poor. This paper examines the prospects and challenges of implementing CBHI scheme in Nigeria.

KEYWORDS: Community Based Health Insurance, Health Care Delivery, Nigeria, Sustainable Development Goal

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Introduction

Community Based Health Insurance (CBHI) is a model which is been regulated within Nigeria

National Health Insurance Scheme (NHIS). The uptake of the scheme has been very

disappointing. One will expect a nation like Nigeria that is  ranked  as  one  of  the  fastest

growing  economy  in  the  world  with  growth  rate  of  6.21  percent  in  2014 from  5.65  in

2008 to solve the lingering health challenges in the rural areas and the full implementation of the

Universal Healthcare Coverage (UHC) through the Community based Health Insurance Scheme

(UNPF, 2014; NBS, 2014). Recently  in  2014,  the  country’s  Gross  Domestic   Product  (GDP)

was  rebased,  making  it  the  largest   economy  in  Africa,  with  a  GDP  of  US  $510billion.

(NBS, 2014).  The   2000 world   health   report  of the  World  Health  Organisation  (WHO)  

have  shown   that  Nigeria’s  health  system  needs  improvement. World  Bank (2013) opined

that the   life   expectancy  of  52  years  is  below  the  Sub -‐ Saharan  Africa’s average (56

years).  Infant  mortality rate  is  39  in  every  1,000  live  births,  under - five  mortality  rate  is

124  in  every  1,000  live  births,  while  maternal  mortality  rate  was  estimated  at  630  (2010

figure)  in  every  100,000  births (The   World   Databank, 2012).

 One  key  factor  is  the  country’s  poor  budgetary   allocation  to  health,  which  has  in  the

past  years  hovered  around  5 - 6  percent  of  total  annual  budget,  and   falls  short  of  the

15%  (US  $14/N2, 268 per  capita  expenditure  on  health)  expected  of  a  developing   country

in   order   to   achieve   the   World   Health   Organization’s   recommendation   for   optimum  

health   coverage  by  2015.The  total  health  expenditure  as  a  percentage  of  GDP  has  not

been  consistent. Increased expenditure caused by the need to cope with injury and illness has

been identified as one of the main factors responsible for driving vulnerable households further

into poverty (WHO, 2000).

Meghan (2010) opined that more than half of health expenditure in poor countries is covered by

out-of-pocket (OOP) payments incurred by households. An increase in such expenditure can

have catastrophic effects and may deplete a household’s ability to generate current and future

income and have inter-generational consequences as households may be compelled to incur debt,

sell productive assets, draw down buffer food stocks, or sacrifice children’s education. Foregoing

medical care may lead to long lasting illness, disability or even death (O’Donnell et al., 2005; De

Weerdt and Dercon, 2006; Flores et al., 2008).

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Community-based health insurance (CBHI) is a not-for-profit mechanism based upon solidarity

among a relatively small group of people. CBHI schemes vary a great deal in terms of who they

cover, how, for what, and at what cost. The majority of CBHI schemes operate in rural areas, and

their members are relatively poor. They are regarded as “local initiative which is built on

traditional coping mechanisms to provide small scale health insurance products specially

designed to meet the needs of low-income households ’’ (Carrin et al as cited in Mugisha and

Mugumya 2010, 181).

To Churchill, (2006) community-based health insurance is an outline of insurance that protects

low-income people against specific disease in exchange for regular premium payments balanced

to the likelihood and cost of the risk concerned.” In the prospect of this, the need arises for the

government to put in motion policies and patterns that will advance the employment of

community health insurance scheme. “According to Rosenthal (2001), rural dwellers may be less

disposed to seek health services owing to the growing costs of medical services if the integrated

health insurance system as set up by the province.” CBHI is also considered as any program

managed and operated by a community-based organization, other than government or a private

for-profit company, that provides risk-pooling to cover the costs (or some part thereof) of health

care services. Beneficiaries are associated with, or involved in the management of community-

based schemes, at least in the choice of the health services it covers. It is voluntary in nature,

formed on the basis of an ethnic of mutual aid, and covers a variety of benefit packages. CBHIs

can be initiated by health facilities, NGOs, trade unions, local communities, local governments

or cooperatives and can be owned and run by any of these organizations (Jutting,(2004) in Tabor

2005).

In Nigeria, households bear the highest burden of health expenditure. A study carried out by

Olakunde (2012), revealed that health financing system is largely characterized by low

investment by the government, extensive out – of - pocket payments, limited insurance coverage,

and low donor funding. Obviously, out –of - pockets account for the highest proportion of health

expenditure in Nigeria. Out – of - pocket expenditure constituted the larger proportion of total

health expenditure averaged 64.59% from 1998 to 2002 (Soyinbo, 2005). In 2003, it accounted

for 74% of total health expenditure. It decreased to 66% in 2004 and later increased to 68% in

2005 (Soyibo, Olaniyan & Lawanson, 2009). Since most Nigerians depend on their pockets to

utilize health services, the low income groups such as the unemployed, poor, disabled, youths,

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housewives and illiterates are usually victims of circumstances leading to low patronage of

health facilities when they need treatment from ill - conditions. This has contributed largely to

the poor health indices in Nigeria especially in areas of maternal and child mortality, HIV/AIDS,

tuberculosis and life expectancy which obviously threaten the achievement of MDGs targets. It is

pertinent to state here that, to achieve a sustainable developed national, its citizens health must

be put into consideration and implemented because a nation with high mortality rate will never

experience sustainable development especially those in the rural areas.

Health insurance encompasses risk-sharing. It is supposed to reduce unforeseeable or even

unaffordable health care costs (in the case of illness) to calculable, regularly paid premiums. But

in Africa, public and private health insurance cover almost exclusively the formal sector, and

therefore achieve a coverage rate of no more than 10 percent of the population. The majority of

African citizens – informal sector workers and the rural population – don’t have access to this

kind of social protection (World Bank, 1994). As a response to the lack of social security, the

negative side-effects of user fees and the persistent problems with health care financing, various

types of community financing, especially for urban and rural self-employed and informal sector

workers, have been recently proposed as a way forward (WHO 2001).

OVERVIEW OF COMMUNITY BASED HEALTH INSURANCE SCHEME

Universal healthcare coverage (UHC) has been difficult to achieve in many developing

countries, especially Nigeria, with large populations remaining over-reliant on direct (out-of-

pocket, OOP) expenses that include over-the-counter payments for medicines and fees for

consultations and procedures (WHO, 2010). The World Health Organization (WHO) views

medical fees as a significant obstacle to healthcare coverage and utilization, and has stated that

the only way to reduce reliance on direct payments is for governments to encourage the risk-

pooling prepayment approach (WHO, 2010). It’s on this ground, community-based health

insurance (CBHI) emerged as an alternative for members in low income families. CBHI schemes

are designed to ensure that sufficient resources are made available for members to access

effective health care (WHO, 2000). It is difficult to find up – to – date details of schemes

currently running in Nigeria or recent national estimates of participation rates. Community-based

health insurance system is an emerging scheme designed with the exclusive purpose of

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improving access to quality health services for low-income rural families who are excluded from

the National Health Insurance Scheme.”

Sound health is necessary for the health of the rural inhabitants. Sound health is similarly

required for economic and societal growth (World Health Organization, 2000). “Workers have to

be good for them to cultivate, and kids have to be healthy to attend school and partake in other

actions.” Inadequate health facility is regularly related to disease and injuries among the rural

inhabitants. At the same time, poor health has another critical impact: it causes poverty, in that

large health expenditure can bankrupt families. (Garba, Ibrahim, Azhar Harun et al, 2015).

According to WHO (2000) the main causes of poor health are insufficient prevention and lack of

practical access to primary health maintenance, along with inadequate nutrition and impure

water. While health-related poverty consequences beginning a lack of risk pooling and insurance

Underfunding of healthcare by government and private organization are key to both of these

negative effects. Furthermore, many African countries especially Nigeria compounds these

problems by making inefficient use of the resources they have for health care and risk pooling.

The results could be required through the utilization of the workable health insurance program

that can improve the well-being of the rural inhabitants.

Metiboba reported in 2011 a statement made in 2009 by Audu, the Secretary for the NHIS, that

only 3% of the entire Nigerian Population was covered. (Metiboba S, 2012). Underlying

problems have been reviewed more recently by Baba and Omotan, who place the poor

performance of Nigeria’s NHIS within the wider context of fragmented approach to healthcare

that involves both Federal and State government, deterioration in the public health service caused

by a “brain drain” and lack of resources and the high levels of poverty encountered in Nigeria.

(Baba & Omotara, 2012).

According to the World Bank, a number of Community Based Health Insurance Schemes

(CBHIs) are growing rapidly; however, they caution that many schemes do fail (Tabor 2005, 5).

John Ataguba (2008) argues that. Many African countries, including Nigeria, Tanzania, Kenya,

Uganda, and Cameroon have community-based health insurance schemes that offer protection

for the poor but are unsustainable because poor people can't contribute enough premiums to

maintain the schemes (Appiah, 2012).

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CLASSICFICATIONS OF COMMUNITY BASED HEALTH INSURANCE SCHEME

Classification of Community Based Health Insurance can be done in several ways in accordance

to the kind of benefit provided, circumstances of their creation, and levels of risk pooling,

management and ownership, irrespective of their class, they all possess some level of similarities

such as voluntary membership, prepayment of contributions and entitlement to specific benefits.

The scheme is design as not – for - profit making in all ramifications. CBHI schemes are noted

for the principal role of a community involvement in raising funds, pooling (accrued prepaid

healthcare funds on behalf of a population (Kutzin, 2001), allocation of funds, purchasing

(Mclntrye.D, 2007 & Kutzin, 2001), and supervision of healthcare financing arrangement.

CBHI is the application of insurance principle by the community in conjunction with NGOs,

healthcare providers which is solely directed by their community choice and is based on their

arrangement and structures. These schemes originated on the basis of an ethnic mutual aid,

collective pooling of health risks and solidarity in which members participate efficiently in its

functioning and management. It is voluntary, autonomous, and not – for – profit organisation.

Payments are collected by community in advance of treatment and this is managed in paying for

providers. (Atim, 1998).

TYPES OF COMMUNITY BASED HEALTH INSURANCE FINANCING SCHEMES

There are three major types of community based health financing schemes namely:

i). Community prepayment health organizationsii). Provider based health insuranceiii). Government – run but community – involved health insurance.

These schemes differ in terms of its design and the involvement of the community in setting it

up, mobilization of resources, its management and supervision.

i. COMMUNITY HEALTH PREPAYEMENT SCHEME:

These types of health organizations are characterized by voluntary membership and payments are

made in advance in order to cover potential medical costs. Members of the schemes pay

premiums on a regular basis, usually when their incomes are high. Such schemes are often

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initiated with the technical and financial support of NGOs and thereafter the community takes

full responsibility for administering and managing the scheme. Local governments may also play

a role in encouraging and supporting the efforts of such schemes. The community participates in

designing the scheme and decides on the level of benefit and the corresponding premium. In

addition, members participate actively in the administration and supervision (Arhin-Tenkorang,

2001). While community involvement is a purported strength of this approach it is also a

weakness as the establishment and continuity of such schemes depends on social solidarity and

trust amongst community members. (The   National   Health   Insurance   Scheme). Poor

management and accounting skills may also undermine the sustainability of such schemes.

ii. PROVIDER BASED HEALTH INSURANCE:

These types of health insurance schemes are initiated by healthcare providers (such as a town or

regional hospitals) to encourage utilization of healthcare services. This review contains seven

studies which may be placed under this rubric. The schemes mainly cover expensive inpatient

care and hospitals and may have recourse to external funds to subsidize service costs. In this

framework, the health care providers are responsible for mobilizing resources and providing

health care services. The role of the community in designing and administering the scheme is

limited. However, members of the schemes are given a chance to participate in scheme

supervision and provide feedback on service quality through meetings organized by the health

care providers. Such schemes are often restricted to those households living in the catchment

area of a health facility (Arhin-Tenkorang, 2001).

iii. GOVERNMENT RUN COMMUNITY – INVOLVED HEALTH INSURANCE:

Government run community-involved health insurance schemes are often linked to formal social

insurance programmes with the objective of creating access to a universal health care system

(Jakab and Krishnan, 2001). Unlike other models, government initiated schemes often cover both

basic curative and impatient care. The government (national or regional) plays a substantial role

in initiating, designing and implementation of such schemes (Arhin-Tenkorang, 2001). The

participation of the community in such schemes varies substantially across countries. Some

governments create conditions which enable community involvement in defining the benefit

package, setting of premiums and scheme management while others introduce the schemes in a

top-down manner and limit the role of the community. Membership in such government-initiated

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health insurance may not always be voluntary. Twenty five studies in this review fall in the

category of government-run models of community health insurance schemes. (Isaac   A, 2014)

Unlike other forms of CBHI, government supported health insurance schemes have the potential

to reach a relatively large number of households. Governments in co-operation with donor

agencies may provide reductions in premium and fee waivers for the poorest segments of society

while retaining a universal benefit package. The disadvantage of these schemes may lie in their

design and implementation features. Since such programmes are the result of a top-down

approach, they may not be sensitive to local needs. Limiting the role of community participation

in awareness-raising, decision-making and supervision probably robs such schemes of a sense of

ownership which in turn may hamper sustainability.

THEORETICAL FRAMEWORK

There are many theories developed by different scholars that can be used in explaining CBHIs,

but for the purpose of clarity, social mobilization Theory and social capital theory was

adopted for the explanation of CBHIs, even though CBHIs is not functional in the country

(Nigeria).

Social Mobility Theory:

Social mobilization theory has been proven as effective for health promotion especially when people

are reluctant to respond positively to health programme. In the case of CBHI, people need to be

mobilized in order to understand and to adhere to the program given the fact that most of people do

not see direct benefits of health insurance (time inconsistence problem). Hence, this section develops

social mobilization theory and shows how it leads to social and behavior change through effective

communication. Social mobilization is a multi-level, dynamic approach that can be initiated either

top-down or bottom-up. Community is perceived in its broadest sense to include all those who have a

role and responsibility in effecting change. As information is made available and understandable to

both experts and lay people, broad ownership and popular support are created (Russel and Levitt-

Dayal, 2003).

Social mobilization refers to “the use of planned actions and processes to reach, influence, and

involve all stakeholders across all relevant/pertinent/involved/concerned sectors, including the

national and the community level to raise awareness, change behavior, change policy, demand a

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particular development programme, or reallocate resources or services. The social mobilization

approach can be used in different health issues including safe motherhood, community based health

insurance, family planning, HIV/AIDS prevention, girls education and so on.

A community based health insurance like any other health program, to be effective, needs a multi-

pronged approach of social mobilization that encompassed communication through dialogue at

multiple levels and among multiple audiences. It also requires broaden public support through

community mobilization. Here Community mobilization refers to a process of problem identification

and problem solving stimulated by a community itself or facilitated by others that involves local

institutions, local leaders, community groups and members of the community (CEDPA, 2000 ).

Community mobilization uses deliberate, participatory processes to involve local institutions, local

leaders, community groups, and members of the community to organize for collective action toward

a common purpose. Community mobilization is characterized by respect for the community and its

needs.

For social mobilization to be successful and to build this base of popular support, communication

needs to be a process of dialogue, information sharing, mutual understanding, and collective

action. Standardized messages are used to promote a dialogue within the community as a whole

(Aubel, 2001). It should also be noted that the CBHI to be sustainable needs mobilization for

human and financial resources. Neil McKee (1992) lists five main approaches to mobilizing

human and financial resources: (1) political mobilization, (2) government mobilization, (3)

community mobilization, (4) corporate mobilization, and (5) beneficiary mobilization. Social

mobilization uses community events to attract the attention of policy makers, community

members, and media representatives and motivate them to take action on a specific issue such as

immunization, literacy, or family planning. Social mobilization amplifies advocacy activities,

strengthens communication, and allows many more societal partners to participate in the

program. To be successful a CBHI program needs to use all those approaches to mobilize human

and financial resources.

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Social capital theory:

Putnam (1993), the first scholar to popularize social capital theory, argues that social capital

consists of “features of social organization such as networks, norms, and social trust that

facilitate coordination and cooperation for mutual benefit” (Putnam, 1993). He asserts that

informal networks of civic engagement build social capital which in turn facilitates improved

governance. Michael Woolcock takes the theory a bit farther by breaking social capital into four

categories: (i) bonding social capital inhering in micro level intra-community ties; (ii) bridging

social capital inhering in micro level extra-community networks; (iii) bridging social capital

inhering in relations between communities and macro-level state institutions; and (iv) bonding

social capital inhering in macro level social relations within public institutions (Maldovsky and

Mossialos, 2006).

According to Woolcock and Narayan (2000) social capital helps the poor to manage risk and

vulnerability. Thus, CBHI which aims at managing risk and vulnerability may be well accepted

by a community that possesses a high stock of social capital. A high level of social capital is

associated with a high level of altruism among individuals; this makes it possible to take into

consideration the well-being of other members of the group. The presence of social capital

always has a positive effect on a community’s welfare. Fukuyama (1995) asserted that “social

capital can be defined simply as the existence of a certain set of informal values or norms shared

among the members of a group that permit cooperation among them. Sobel (2002) describes

social capital as circumstances in which individuals can benefit from group membership. Thus,

social capital refers to social life networks, norms, and trust that enable households to act

together more effectively to pursue shared objectives. This social capital in the community can

be an asset for the breakthrough of CBHI, thus contributing to the demand for CBHI at the

community level.

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Due to the nature of CBHI schemes, their success therefore depends largely on the existence and

survival of social capital in the community. CBHI can therefore attain sustainability,

effectiveness and be long-lasting with the help of social capital in a community; because social

capital has a positive influence on the community demand for insurance (Donfouet HPP,

Mahieu, 2012).

More so, evidence has shown that social capital18 acts positively on the value people attach to

their health. Weak level of social capital amongst members of a group results in an increasing

risk of experiencing self-centered behavior at its peak of anti-selection and moral risk

(Mladovsky & Mossialos, 2008). On the other hand, high level of social capital affects

households’ decision on health insurance which in turn increases the demand for CBHI

(Donfouet & Mahieu, 2012). As shown in table 2 below:

Table 1: Social capital and network links

SOCIAL CAPITAL

1. Network Links

Between different communities (vertical) and similar communities

(horizontal)

2. Community Links

Between extended families clubs, local organizations, civic groups and

Association

3. Societal links

Between government and citizens via community participation and public -

private partnerships

4. Institutional Links

To communities, legal, political and cultural environments

Source: Preker et al 2002

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Figure 1: Generic conceptual framework for analyzing uptake of CBHIs

Sources: Adebayo, 2014.

Key to framework

A* – Fundamental factors evolving around uptake of community based health insurance

Socio-demographic factors: age, sex, geographic location, education, marital status, head of

household, household size, employment status, wealth quintile and membership of an

association.

Health related factors: illness experience, state of health, utilization of health facilities, and

quality of health services, availability of drugs and medical supplies and health care workforce

Other factors: Trust, relationship and distance to health facilities.

B* – Characteristics of the scheme (managerial, technical, institutional)

Dimensions of programmes and Social capital scheme (political, economic, managerial and

social).

D*

C*

B*

A*

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C* - Role of government (subsidies, policy framework and implementation, technical support)

Role of community (ownership and support).

D* - Social protection.

CHALLENGES OF COMMUNITY BASED HEALTH SCHEME

The scheme has not been visible in Nigeria and its uptake has been faced with lots of challenges.

The major challenges are: Fraud and corruption, Management Capacity, Poor Awareness, Poor

services, Poor Incentives, Attrition (withdrawal or loss members) and Payment of Premium.

Management Capacity:A weakness in management capacity is one of the most severe problems faced by the CBHIs. The

weak CBHI management capacity includes a failure to adequately manage insurance risks, unrealistic

premiums, the absence of a community business culture, low controls for fraud, limited coverage

(and hence high risk of adverse selection), absence of qualified staff trained in insurance, lack of

marketing surveys to link products to perceived needs, limited marketing beyond the pilot phase,

poor data handling and management capacities, and stiff competition from highly subsidized

government hospitals and national social health insurance agencies ( McCord and Osinde 2002;

Musau, 1999).

In practice, many CBHIs have managers who are not well-versed in insurance, finance, or in the

basics of business management. That is because CBHIs are managed on a voluntary basis and draw

on existing members as elected managers. McCord argues that weak management can lead to the

rapid erosion of trust. It is one of the main reasons given for the demise of new schemes (McCord,

2002). Banerjee and Duflo added that the lack of trust leads to another problem of lack of credibility

on the insurance provider. Credibility is very crucial for the insurance provider because the insurance

contract that the insurer enters in with the insured requires the individual who is to be insured to pay

in advance. This means that the insured individual is required to trust the insurer completely. Hence

lack of credibility becomes a huge problem especially when insurance companies are unable to

address clearly the problem of fraud or when the nature of the products is unclear (Banerjee and

Duflo, 2011). Management information systems –manual or computerized –are also critical to the

effective operation of a CBHI. It becomes extremely difficult to manage a program without the

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ability to track premium payments, utilization, and other costs. Integrating hands-on management

controls with information systems can help CBHIs cut costs and improve service

According to Tabor, there are different problems related to the context in which CBHI is designed

and implemented, such as poverty, awareness, and covariate risk (Tabor, 2005). CBHIs become

successful when the context in which it has been designed, and in which it is being implanted, is

favorable. In case that context is not good, the design and the implementation of the scheme are also

somehow negatively affected.

Payment of Premium:

Severe poverty can slow down the success of a CBHI. If most people are simply struggling to

survive, they will be less willing to pay insurance premiums in advance to use services at a latter

point in time. In fact the poor are the most vulnerable in a society because they are the most exposed

to the whole range of risks and at the same time they have the least access to appropriate risk

management instruments. The poor have only recourse to coping mechanisms: they try to cope with

the risk when it has already occurred (Holzmann & Jorgensen, 2001). Besides money, payment

modalities can also present problems. If the annual premium must be paid in a lump sum (instead of

payments spread out over the year), households find it more difficult to pay.

According to Morestin and Ridde ( 2010 ), in Burkina Faso, for instance, the households stressed that

a single payment is more problematic in rural areas, where it is hard to obtain credit. Another element

is the time at which the payment is due. Incomes of workers in the informal or agricultural sectors

vary over the course of the year. Apart from the problems related to poverty, there is also another

problem of awareness. There is an argument that most of the time the poor do not understand the

concept of insurance very well. It is true that insurance is unlike most transactions that the poor are

used to. It is something that you pay for, hoping that you will never need to make use of it (Banerjee

and Dulfo 2012). Cultural norms and values also play a role. If people see disease as a punishment

for evil behavior, they will not join a CBHI. In some parts of rural Benin, for example, saving money

for a disease was seen to be “wishing oneself the disease” (Tabor, 2005). Tabor also argues that

under-insurance, or the choice of an individual to buy less insurance than is needed or could be

afforded, can occur when people don’t understand the benefits that insurance can bring. Drop-out

rates can be very high in cases where individuals feel that the benefits should correspond to the

contributions they have made (i.e. savings concepts).

Fraud and corruption:

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Corruption is a disease that eaten into the fabrics of Nigeria economy and developmental process.

Fraud and corruption are among the major problems that hold back the implementation of CBHI

schemes. Health insurance is subject to the risk of fraud, or deceptions intentionally practiced by

patients, providers, and CBHI staff and managers, to secure unfair or unlawful gain (Tabor, 2005

p.39). McCord and Osinde (2002) argue that lack of professional management can make CBHIs

vulnerable to fraud. In the case of Tanzania’s UMASIDA CBHI, group leaders were selected from

the local communities. They were not professional managers, yet they had a great deal of financial

responsibility. Several of them became frustrated with all the work involved and found

themselves tempted by the premiums. Hence, many of these groups experienced a change in

leadership because of fraud (McCord & Osinde, 2002).

Apart from the fraud on behalf of mangers, cases of fraud on behalf of patients have been reported by

the CBHIs managers at different health facilities in Rwanda. Normally, new subscribers had to wait

one month before enjoying their contributions. At times, however, they did not want to respect that

period and, as a result, wanted to corrupt CBHI managers in order to get treatment before the due

date. Until we start having a right frame of mind towards achieving success especially when it comes

to handling of money for the execution of projects, we will never get it right and will also remand the

way and stage we are today.

Attrition (withdrawal or loss of members):

Loss  of  members,  either  voluntarily  or  due  to  other  reasons,  has  been  a  key  deterrent  to  the

coverage  and  success  of  the  scheme.  It  has  been  difficult  to  retain  them,  and  this  has  been  

attributed  to  poverty  and  inadequate  information  on  the  scheme.  Participants,  especially  the  

poor,  may  sometimes  find  it  challenging  to  consistently  pay  premium  monthly  and  even

harder  to  pay  the  accompanying  fines  (as  in   case the  Ikosi -‐ Isheri  scheme);  as  a  result

there  are  too  many  inactive  members  in  the  scheme.

There is Still Poor Awareness:

These are  key  factors responsible  for  the  current  state  of  the  scheme,  though  there  have

been  some effort  to  create  awareness.   Sadly,  these  campaigns  have  not  been  consistent,

though  little  is  still  being  done  during  antenatal and  immunizations  visits. The people

should be probably informed and educated about the programme and its benefits. Until that is

done the Universal Health Coverage will be unachievable.

Lack of Support from the Local Government:

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 The scheme has not benefitted tangibly from the local   government.   One   reason   attributed  

to   this   was   that   the   local   government or   its  representatives  were  not  involved  in  the

planning,  design  and  implementation  of  the  scheme,  a   suggestion  that  the  scheme  is

being  politicized.

Poor Services:

Poor  services  have  also  been  noted  to  be  a   deterrent  to  patronage ,  especially  among

members   who  truly  understand  the  scheme,   but  apparently  were  not  satisfied  with  the

services  rendered   by   the   provider.

Poor Incentives:  

The scheme   still suffers poor incentives for the managers (board of   trustees) the   management

however should tries   to   compensate   members   with   little   incentives   as   sitting  

allowance. So as to encourage and motivate them to stay and render the necessary services.

CONCLUSION / RECOMMENDATIONS

This study has justify its self by reviewing Community Based Health Insurance Scheme in

Nigeria, the types and have been able to apply Social Mobilization Theory and social Capital

Theory to explain the challenges and prospects of Community Based Health Insurance in Nigeria

and other African countries.

Conclusively, for the program to be successful,   all noted   challenges must be addressed.  There

should   be  incentives  for  the  BoT ( the workers),  either  as  salary  or  other  benefits.  Also,

it  must  be  free  of  politics  or   engaging politicians  in  the  management  of  the  scheme. The

success  of  the  CBHIS  and  its  ability  to  achieve  its  goals  including  achieving  UHC  in

Nigeria   depend  greatly  on  the  sustainability  of  the  program  and  the  ability  to  scale  it

up.  Ownership,   political  will,  local  leadership,  as  well  as  motivation  and  building  trust

in  the  people  have  been   identified  as  key  factors  for  the  success  of  the  program.9

This  study  is  not  exhaustive;  more  still  needs  to  be  done  in  terms  of  research in order  to

develop  a  robust  study  report. First,   perception   and  satisfaction   surveys are necessary  to

understand   people’s  opinion,  knowledge,  and  use  of  the  program.   Also,  there  must  be

well  planned  and  well   implemented  monitoring  and  evaluation  programs .  The findings

from  these  processes   will not   only  help  churn  out  vital  statistics,  they  also  will  help

promote  the  sustainability  of  the  scheme so as to achieve a sustainable development Goal.

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The findings from this study further necessitate the following recommendations that will help to

improve the programme in the country if been implemented by the policy makers:

i. Program design should be community specific.  By this, each community must be seen as

unique with   its   own   characteristics,   though   may   share   similarities   with   other.

Socio- ‐ demographic   factors   such   as   income   status   and   socio-‐ economic status

of   the   people   must   be   taken   into   consideration.   As  a  result,  the

implementation  of the  scheme  in  that  community  must  share  the  observed

characteristics.

ii. Increased   awareness   among   community   members   in   all   Local   Government  

Areas.   This   is   necessary  and  may  take  the  form  of  community  awareness

campaigns  or   other  means  such  as  use  of  print  and  electronic  media and to  

encourage   participation, promote ownership   among   community   members and

mobilize   resources,   there  be should   community   engagement   and   advocacy   visits

to stakeholders   in the community.

iii. The  services  provided  must be  of quality  and  deliver  in a manner  that   meets the

needs  of  the  users.  This  is  necessary  to  build  trust  and  confidence  in  the  system.

This will encourage users to   pay   premium   in   timely   manner,   knowing   that   they

will   get   the   benefits   in   the   future   of   a   payment   today. It  will  also  encourage

them  to  invite  others  to  use  the  scheme.

iv. This   scheme   should   be   devoid   of   politics   such   as   party   partisanship,  

nepotism   etc. Local   government  must  be  engaged  appropriately,  irrespective  of

political  differences  or affiliations.

v. Coverage  is  very  low  and  may  take  many  years,  beyond  the  2015  goal  to achieve

universal  health  coverage  in  Nigeria.  There  is  still  a  lot  to  be  done  as  majority of

the  members  either  drop  out  or  remain  inactive  due  to  couple  of  reasons,  either

because  they  could  not  afford  continuity  of  renewing  premium   or   not   benefitting

from the   services   as   thought   they   would.  A   further   research   would   be

beneficial in this respect.

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