Towards Health Financing for Communities by Communities

Background

Earlier this year, I had an experience that inspired me to think critically in the direction of community financing as the most viable alternative in solving the current healthcare financing gap in Nigeria and other LMICs. I was rotating through Wesley Guild Hospital's Orthopaedics and Trauma department, and we had a patient, a commercial driver who sustained multiple fractures from a road traffic accident in the peak of the December festivities. He and his family could not provide the needed funds for his urgent management.

Such a scenario is not unusual in rural-based hospitals like ours – many of those who end up on our hospital beds usually do not have enough funds to pursue the necessary investigations, treatment, and other attached costs. We (doctors) often have to make financial donations to see our patients survive.

However, the commercial driver's story changed when the local branch of the National Union of Road Transport Workers (NURTW), the community of commercial drivers in the township, came to his aid. The Union raised over 70% of his hospital bills. I was surprised because, before that time, all I knew about the Union were stories of horror and terror (Nigerians can relate). I assumed they had an organised contributory scheme for helping members with road traffic injuries.

Upon inquiry from members of the Union who visited the patient, I found out that they had no particular contributory scheme for such purpose but only organised themselves at the moment to make donations for the patient. One of them mentioned that road traffic accident are unplanned and could happen to anyone. And so they thought it necessary to help the victim. 

From then, I began thinking about the potential of exploring community-based healthcare financing schemes for people and groups who share common values and are affected by the same problems. Seeing what they did with a random call for donations, I wondered how much could be achieved with a well-planned, organised, and professionally administered contributory program for health.

The Problem

In Nigeria, health financing challenges remain a significant hindrance to public health goals. For a country where majority live below a dollar per day, there is little that the out-of-pocket payment system, the most used health financing option, can cover. Our health services depend mainly on direct government funding and foreign aid for infrastructure, technical support, and capacity building to subsidize users' costs.

Despite the subsidy, healthcare by pocket payment is still not affordable for most poor Nigerians. Unfortunately, those poor Nigerians, who live primarily in rural and remote locations, end up needing healthcare the most, indubitably not unconnected to the inadequate primary health care services.  It's a vicious cycle of poverty, lack of access to preventive health care services, health complications, higher healthcare costs, and worsening poverty. It all leads to abject poverty. And this is not limited to those in rural areas alone.

So why does this matter?

I often argue that there is no middle class in countries like Nigeria; instead, we have an upper class that is very distant from the lower class. The so-called middle class is a group of people who manage to survive and are only a medical diagnosis away from abject poverty.

Many Nigerian families will be in financial turmoil if a family member comes down with kidney disease, cancer, or other debilitating health conditions requiring long-term care. 

The health financing problem on our hands is deep - our two-decades-old National Health Insurance Scheme (NHIS) currently covers less than 5% of the country's population. The various sub-national health insurance programs that augment the national plan have also not achieved much. This is because the scheme mainly covers individuals working in the formal sector. Solving the problem would require unconventional approaches.

What we should do

To cover the gaps, we must look into the possibilities of engaging communities to organize them towards community-based health financing. These include geographical communities in remote areas, vulnerable groups, or artisan-based communities like the NURTW. Although this option has been tried by a few Health Maintenance Organisations (HMOs) in Nigeria, there has not been significant progress on it because the HMOs, to a large extent are profit-oriented and would ordinarily factor in service and administration charges into the premiums of health insurance subscription plans, even if intended for communities.

The relatively high cost of purchasing private health insurance plans in Nigeria makes it difficult to have a large pool of subscribers. And health insurance is all about resource pooling and risk sharing; the wider the pool, the more extensive the coverage, and the more value can be gotten. Some also argue that community-based health finance schemes cannot work because the exiguous contributions by the communities cannot cover the expensive costs of advanced healthcare.

But maybe we need to view it from another angle.

What if we could help communities design community-based health financing strategies focusing on health promotion and disease prevention?

I have posited in the past that communities are best positioned for PHC when empowered to participate in their healthcare processes. Ergo, we can work towards creating community health financing strategies, run by communities, for the communities, and supervised by professionals. To do this, the HMOs must view community-based financing as a CSR commitment to their immediate communities. Without focusing on profit, they should help the communities organise resource pools strategically designed to cover the communities' prevalent and most basic health needs.

Also, we can engage communities to organise their resources - all factors of production - for PHC strengthening. For example, when British missionaries came to set up Wesley Guild Hospital (where I currently work) in Ilesa, Osun State, in the early 20th century, it was said that the Ijesa people espoused its development. The community provided land at a strategic location for the hospital and selected some members to jointly build the first hospital structure. The people saw the project as a common good and ensured to provide food products from their farms to the health workers. They carried out many essential services for the hospital missionaries free of charge.

These gestures continued for several years and helped reduce the healthcare financial burden of the community. This is very similar to the activities of Friendly Societies in the 19th century U.K and the historical traditional solidarity or welfare mechanisms of West Africa. All of that can be replicated now, although in redefined ways and in line with today's realities.

Conclusion

I think the prospect of utilising community-based financing plans in healthcare is currently under-discussed, especially in LMICs - where conventional health insurance programs are not working. All healthcare stakeholders should work towards prioritising crucial discussions on the design and implementation of efficient community financing strategies for health.

I reiterate that we will achieve better outcomes when we empower people and communities to become major participants in their health care plan.

I hope we reflect on this!

Till next time,

DSA