Case study: Leveraging health insurance systems to provide essential services for vulnerable populations in Kano, Nigeria
Kano State is one of the most populous states in Nigeria with an estimated 13.4 million people. Over 70 percent of the population is deemed financially vulnerable. Combined with the low coverage of prepaid health financing mechanisms like health insurance in the state and country at large, the poverty levels have perverse implications for socio-economic indicators and standards of living.
Take for instance the case of Sadiya who is a married adolescent that lives in a rural part of Kano. She contracted a sexually transmitted disease during her pregnancy, but could not afford to buy the medicine she needed to treat the infection, nor travel to the hospital where the medication was available. For Sadiya, and many of her peers, accessing sexual and reproductive health services at the hospital is almost impossible because of the many barriers they must overcome. These barriers range from poor awareness and access to information about health services, to unaffordable costs associated with doctor’s appointments, treatment, and travel.
The state government has prioritized health systems strengthening interventions that will improve the quality of healthcare and reduce out-of-pocket expenses for women like Sadiya, as well as other vulnerable groups. In 2016, the government signed a bill that established the Kano State Contributory Healthcare Management Agency (KSCHMA). KSCHMA is a health insurance agency that subsidizes health services to make sure residents have access to quality, affordable care, especially for essential maternal, newborn, and child health services, like antenatal care, malaria treatment, and basic obstetric care.
However, it became clear that the program was leaving behind vulnerable groups, like women and children in rural communities, who could not afford even the subsidized prices for services being offered.
A separate program was needed to provide free health services to these vulnerable populations. This realization underpinned the establishment and pilot of the Vulnerable Populations Programme (VPP) which aims to ensure equitable distribution of quality, free health services to financially vulnerable populations in the state by tackling demand-side financing bottlenecks. CHAI is supporting the end-to-end operationalization of the program by identifying the operational needs of the government, designing sustainable and efficient business processes that enable the program to be scaled and its scope expanded, and building government’s capacity to adopt these improved processes and technologies for longer-term implementation.
In 2018, CHAI began working with KSCHMA to conduct a health financing landscape assessment which uncovered challenges in the expansion of health insurance coverage to vulnerable populations. The results from the scoping were used to identify strategic areas of support that would be most responsive to the state’s needs. CHAI worked collaboratively with state leadership to create a microplan that would guide our scope of work. On the supply side, we held stakeholder engagement meetings to identify viable and sustainable funding sources to finance essential health services for vulnerable populations; worked with state leadership to develop and cost implementation plans for the program; and supported the creation of data systems to monitor, evaluate, and report on the program’s milestones. CHAI also built the capacity of agency staff on basic data collection and analysis so they could provide better quality assurance supportive supervision. We also conducted financial management training for primary healthcare facility staff to strengthen facility-level management systems and improve efficient resource use.
On the demand side, CHAI worked with KSCHMA across all 44 local government areas (LGAs) to develop and deploy materials to help sensitize community leaders and beneficiaries on the objectives of the program and identify women and children who were eligible. We also supported the development of beneficiary tracking tools to have end-to-end visibility into indicators that pertain to the VPP.
With the operationalization of the VPP in Kano, Sadiya says, “I used to feel very hopeless to come to the health facility. When I got this infection, I was so worried because due to the COVID-19 pandemic, a lot of men had to be confined to their premises – no going out meant no going to the market for their normal business activities…my husband had nothing doing because the markets were shut down, and some days we had nothing to eat.
“Even after coming to the facility, I could not afford the prescribed drugs. I was eventually informed that there was a new program by the state government and was lucky to be one of the beneficiaries. I can now access services for free until my delivery. I have, for the very first time, attended ANC [an antenatal care clinic] and I am happy with the counselling I received and will also use the drugs prescribed for me.”
Nafisa, married with five children and another one on the way, said she feared for her situation before being accepted into the VPP. “My husband doesn’t earn much, and we all depend on his income for our everyday needs…I had on several accounts intended to go to the hospital for the uptake of family planning but couldn’t because I had no money. I kept procrastinating until I found out I was pregnant with this current one. I couldn’t do much about my situation until I got into the VPP, and had access to free ANC services. I can’t change my pregnancy situation, but now I know I can come to the hospital for a proper check-up and when the medicine is prescribed, I can go to the pharmacy to collect my prescription for free. I was very lucky to do [an ultrasound] at no cost, unlike before when I had to pay N1,200 (US$3). Thanks to the VPP, I am now able to go for every scheduled antenatal visit without fear of the money I will spend to run the necessary tests, scans, or buy drugs. Before [I would] endure the pain just to cut financial costs for my family. This time around I will go to the hospital and deliver and take up family planning immediately after I deliver this child.”
We also heard from Abu, a widow that lives in Tanawa ward – a rural community in Kura LGA. She said “I have eight children out of which three have sickle cell anemia. The journey has not been an easy one especially after the passing of my husband. Even though on some days I do not have the money to travel to access services from any health facility, I must shoulder the responsibilities including the routine drugs to support my children that have this condition. We are mostly in the health facility for pain management and to help prevent further complications. In some cases my children require hospitalization, and we have no support financially. I lost my job in the rice mills because I spent so much time taking care of the children. So, with this new program by the state government, the inclusion of persons living with sickle cell into the program is going bring a lot of relief to families like mine. I cannot express my joy when I was told that my children were selected to benefit from the program.”
The VPP has created a roadmap for what inclusive health financing systems for Nigeria’s most vulnerable populations could look like and provides a pathway that can be scaled. Through the operationalization and documentation of this pilot, CHAI has supported the government to work through potential implementation challenges, address technical capacity constraints and generate lessons that can support recalibration and course correction as efforts are being made to scale up affordable healthcare access to vulnerable groups.