There have been many calls for universal health coverage recently. Nigeria is one of the signatories to the universal health coverage plan which states that citizens must be able to access health facilities without payment at the point of getting that service. One of the models through which this can be delivered is community health insurance. There are now a number of community health insurance programmes in Nigeria. The biggest attraction of community health insurance as a model for delivering universal health coverage is probably its inclusion of the community, the insurer, the provider and sometimes a third party in its management. We have been on the lookout for a programme where this works. And we finally found one.
Recently, we visited one of the more successful community health insurance programmes in Obio, Rivers State of Nigeria. This programme is managed by a tripartite arrangement between Shell Petroleum Development Corporation (SPDC), the Rivers State Government and the people of Obio communities, which can be described as a people/public/private partnership to deliver on health care.
Involving the ‘people’ is a principle that receives a lot of lip service but is rarely implemented. In Obio, people are definitely involved. Leadership for the entire project is provided by a community development board, and they decide on all important issues including fund allocation. The traditional ruler is very involved in ensuring that community governance arrangements are in place.
All over the country, hospitals are empty because doctors are on strike, so why is this hospital in Obio buzzing with activity? In this small cottage hospital in the heart of Port Harcourt, there are about 300 deliveries a month, constant power, at least two doctors on site 24/7, an ambulance on standby 24/7 and yet most people do not pay more for their care beyond a N7,200 contribution per year as part of a Community Health Insurance Scheme. This programme, was initiated by SPDC as part of their community health, when they came to the realization that just building and giving infrastructure and equipment to communities was not working and to really achieve sustainable development, people have to be active participants in social services targeted at them.
All over Obio hospital, we saw signs educating the patients on their rights. We spent an hour chatting with Patricia, the “Client Services Manager”. Further to a complaint by a patient recently, the lavatories had been completely moved from one location in the hospital to another. Patricia tells me that this was just one example to the patient community that the hospital listens to them. Everyone has access to her, and they know that their suggestions or complaints will not be ignored. Once patients are discharged, they get an SMS checking up on them, and about 25% of new mothers will be visited at home after discharge by Patricia and her team. The mothers never forget this.
Most clinical settings in Nigeria have a very strict hierarchy. Doctors call their seniors “Chiefs” and defer almost completely to their authority. This hierarchical structure instills a culture of fear, and issues are never really discussed in the open. This hierarchical culture is almost absent in Obio. As Dr Chidozie, the Medical Director took us round the hospital, staff greeted subtly and continued to work. He still has an active clinical schedule everyday in addition to his leadership responsibilities. He tells me that he has not been to his office today and that this would not be unusual. He walks several miles a day, just around the small hospital complex.
The hospital is now financially independent of SPDC and functions mostly on its own. Although SPDC still provides some support, SPDC now mostly focuses on learning from this model and exploring its replicability in other settings. So, what makes this hospital work? Why are the staff energetic and enthusiastic about their work I asked Dr Chidozie and his team before we left. He tells me that there are probable three main reasons for this.
Firstly, at the conversion of the hospital from a traditional tax funded model to community health insurance model, many staff members asked to be transferred out as the work load increased exponentially. So the staff that stayed back was a natural selection of self-motivated workers. In addition to this, they were joined by a lot of self-motivated volunteers. Secondly, the hospital has a zero tolerance for corruption. Any staff found embezzling resources in any way is named and shamed and then relived of his/her position – no ifs, no buts. Thirdly, a culture of collective leadership has emerged in Obio; all staff members feel that they have a stake as well as a reward in the successful running of the hospital.
Obio has been attracting a lot of attention lately, as different groups come to visit to find out more about it and what makes it work. There is a lot to learn from Obio, on several fronts: on successful community engagement, successful healthcare delivery and creating a happy community. I was told about how the gardeners in Obio had formed themselves into a choir to sing as they worked, and I smiled about the spirit of Nigerians when it is let loose. One day, we will sing as these gardeners when our country begins to achieve its full potential; but in the meantime there is much work to be done.
Here at Nigeria Health Watch, we will be studying the evolution of community health insurance in Nigeria and producing a report on key learning points. If you are interested in this, write us at firstname.lastname@example.org.