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Type Conference Paper - London: Consortium for Research on Equitable Health Systems, London School of Hygiene and Tropical Medicine
Title Community based health insurance scheme in Anambra State, Nigeria: an analysis of policy development, implementation and equity effects
Publication (Day/Month/Year) 2009
URL http://www.crehs.lshtm.ac.uk/downloads/publications/Community_based_health_insurance_Nigeria.pdf
Community-based Health Insurance (CBHI) is a not-for-profit type of health insurance that has been used by poor
people to protect themselves against the financial risk of illness. In CBHI schemes, members regularly pay small
premiums into a collective fund, which is then used to pay for health costs if they require services. Based on the
concepts of mutual aid and social solidarity, many CBHI schemes are designed for people that live and work in
the rural and informal sectors who are unable to get adequate public, private, or employer-sponsored health
insurance (Bennett et al. 2004).
CBHI was initiated in 2003 in Anambra state, Nigeria, with the overarching goal of increasing the provision and
utilisation of health services. Before this, there had been declining levels of health care delivery, partly due to
budget constraints, industrial action and the ensuing closure of all public health facilities (Uzochukwu and
Onwujekwe 2005); and utilization of public health facilities and immunization coverage was also low (Uzochukwu
et al 2004, State Ministry of Health 2005a).
However, some studies from other countries in sub-Saharan Africa and Asia suggest that CBHI operations have
only had limited successes in ensuring affordable, participatory, and sustainable access to health care (Bennett et
al. 2004). Furthermore, the benefits of policies that are intended to benefit poor people are often inappropriately
(and sometimes disproportionately) captured by more wealthy and powerful groups (Victora et al., 2002; Goudge
et al., 2003; Bitran and Gideon, 2003; Palmer et al., 2004). There is also some evidence that policies intended to
promote equity can have unexpected negative impacts, such as reduced quality of services (Uzochukwu and
Onwujekwe, 2005).
Despite wider recognition of the need for policy change (Grindle and Thomas, 1991; Hill and Hupe, 2002), there
has been only limited consideration of how the forces underlying the processes of designing, implementing and
managing CBHI policies can influence their success or otherwise. Moreover, where such processes have been
considered, the conclusions have been quite narrowly focussed – concentrating, for example, on the need for
better policy design that takes greater account of the needs of poor people, or implementation processes that just
allow for experimentation and adaptation in response to experience (Gwatkin et al., 2005). Although both issues
are important, they do not address the fact that these processes always involve contestation, bargaining and
negotiation among a range of actors who, either deliberately or by chance, make decisions that shape policy,
including how it is experienced by those it is intended to benefit (Walt and Gilson, 1994).
Some studies highlight such influences over equity-promoting health policy implementation. They show, for
example, that:
weak management of critical interest groups during policy development may shape the design of new policies
in ways that limit their equity-promoting potential (McIntyre et al., 2003; Thomas and Gilson, 2004);
limited efforts to engage with local level managers and providers about new policies may mean that they do
not fully understand policy intentions and so implement guidelines and procedures incorrectly, or even avoid
implementing new procedures. (Kamuzora, 2005);
poor coordination among implementing actors can undermine or pervert effective implementation (Blaauw et
al., 2003);
the failure to take account of existing power structures within local settings, when designing and implementing
new policies, may lead to unrealistic expectations about the role of community members, particularly
marginalized community members, in local decision-making structures that intend to promote local influence
over health care (Gilson et al., 2001; Ngulube, 2005).
Although rarely examined, past studies of CBHI have provided some indications of the way implementation
processes influence experience. For example, a study of the Community Health Financing (CHF) scheme in
Tanzania has shown that managerial practices and behaviour, in partial response to a top down imposition of
policy, can undermine effective implementation (Kamuzora, 2005). This study also highlights the importance of
managerial trust to CBHI implementation experience.
More effective implementation of policies that are intended to promote equity will therefore require more than
improved design of policies or further monitoring and evaluation. It must also include active engagement with, and
management of, the range of relevant actors, based on better understanding of the factors influencing their
responses to new policies. For instance, in Nigeria, it is not known whether policy makers and health care
providers took the community views into consideration when fixing the premium and deciding the benefit
packages, and whether the community have been properly sensitized and mobilized for the scheme.
This study explores the CBHI policy development and implementation process and the factors that have
constrained or enhanced its implementations.

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