To the last mile — Can Nigerian states improve health access in rural areas through innovative finance mechanisms?

Residents in rural areas have suffered neglect from various governments. Photo credit: Nigeria Health Watch

Editor’s Note: This week’s Thought Leadership piece comes from Nigeria Health Watch Director of Finance and Administration, Christopher Nnaji. In the midst of discussions around the importance of Universal Health Coverage, he writes about the importance of thinking through state-driven health financing solutions for rural communities where the fear of incurring hospital bills is particularly detrimental to seeking care at the health facility.

Beyond the bustling Nigerian capital cities with tarred roads, fast-moving cars and busy restaurants, it is not uncommon to hear Nigerians in more remote settings lose their lives because “ hospital dey too far from us. Before we go see bike carry us go there, the pikin for don die. That na why we dey buy this ‘agbo’ to drink for fever” or “ If I go hospital go born, they no go answer me until I pay money and I no get am. I go born for house where ah fit give angwan zoma wrapper or ‘omo’ to help me.”

The stories pile up about how access to healthcare is creating an ever-broadening gap between urban and rural communities in Nigeria. Sadder still are cases where people in rural areas ignore critical warning signs and diseases of public health importance, usually leading to many preventable deaths. Not only are these deaths unnecessary, they are also unaccounted for which means that we cannot learn from our mistakes, further weakening our National Health Management Information System (HMIS) for disease surveillance, prevention and management.

Residents in rural areas have suffered neglect from various governments. For instance, it is unimaginable that in 21 stcentury Nigeria, Ihuokpara, a Community in Nkanu East LGA, Enugu State has only one barely functioning primary health centre for a community of over 40,000 people.

The barely functional primary health care centre in Ihuokpara, Enugu State. Photo credit: Nigeria Health Watch

Access to healthcare services involves the quality of care, physical accessibility, availability of the right type of care for those in need, and financial affordability. The utilization of healthcare services is related to the availability, quality and cost of services, as well as the social-economic structure. In rural communities, health services are under-utilised because of glaring gaps in access. The state of the Nigerian health system is dysfunctional and grossly under-funded with a per capita expenditure of US$ 9.44 according to the World Bank’s 2010 report. As a result, Nigeria still has one of the worst health indices in the world and sadly accounts for 14 percent of the world’s maternal deaths.

A short visit to a community like Ihuokpara will make one wonder if there are any elected officials from these communities. It becomes clear that some elected officials entrusted to see to the development of these communities only show up once in every four years during elections to obtain their votes to enable them cling on to the State’s powers and resources.

Image credit: Nigeria Health Watch

Oil-rich and blessed with natural resources, should Nigeria’s Local and State Governments not be capable of providing quality healthcare services for their rural communities? Are none of our leaders even remotely as motivated as Singapore’s Lee Kuan Yew?

Any government looking to successfully bridge the gaps in Nigeria’s health sector must focus on improving health services and facilities for rural dwellers. Working with community leaders would enable the people to take ownership, leading to improved health seeking behaviour. The community influencers and leaders would help debunk erroneous misconceptions that some illnesses cannot be treated in health centres. Again, the need to populate existing primary health centres with well-trained health professionals and adding new ones would encourage repeat visits to the health facilities as trust is being developed between health workers and their patients.

Universal access to healthcare in rural communities across Nigeria would have ripple effects on the economy. Photo credit: Nigeria Health Watch

Secondly, States and Local Governments should facilitate easy access to health facilities through policies that would deliver health insurance to the doorsteps of citizens in rural areas. A lot more work needs to be done to improve the reach of health insurance plans in Nigeria. Currently, many private health insurance plans are expensive and do not cover Nigerians aged 65 and above. These requirements cut off access to health insurance for many rural dwellers. Health Maintenance Organisations (HMOs) and service providers need to be continually monitored to ensure value for money for the consumers while making health insurance affordable for rural dwellers. Anambra and Cross River States have demonstrated that any government that has the confidence of its populace stands a better chance of providing affordable health insurance plans to its people, as it would most likely have a greater pool in its health insurance net in comparison to the pools of private insurance companies.

It is interesting to know that Anambra and Cross River States which are at the early stage of implementing their state health insurance schemes are charging N12,000 as annum premium for basic coverage. The Commissioner for Health, Cross River State, Dr Inyang Asibong shared these plans at Nigeria Health Watch’s recently held policy dialogue. The affordability of these plans equally presents opportunities for those willing to assist, to buy health insurance plans for their relations and neighbours who are unable to afford it. This helps reduce the uncertainty being faced in our rural communities in terms of access to healthcare.

Obinnia Abajue is the Chief Executive Officer at Hygeia HMO Limited. During his talk at the 2017 Future of Health Conference, he said, “Be your brother’s keeper, get a health insurance cover today for you and your family; and help someone else; your worker, dependent, relative… to pay for a plan..” Watch the rest of his talk!

We all should join the advocacy in our various villages each time we visit, by asking the right questions regarding the health status of our loved ones. We should encourage them to speak up when they are not feeling well, demand for quality care at health facilities and emphasise the need for them to visit the health centre at least twice a year, even when they are not sick, for routine check-ups. This advocacy is likely to produce better results because, as Obinnia Abajue said at the 2017 Future of Health Conference, “The Business of Health”, we are our brother’s keepers. There is a shared bond and trust of the relationship between family members than strangers. Equally, make out time to visit primary health centres in your locality to see things for yourself and report to various authorities any observations that may require their attention. This was one key recommendation from our 2019 Health Watch Forum, “Prevent Epidemics: Immunise” where Chika Offor suggested the #AdoptAPHC advocacy as one way of ensuring that services at the primary health facility are monitored. There is no better time than now to start holding our leaders accountable. These are ways build an active citizenship for health.

Health is wealth. Therefore, universal access to healthcare in rural communities across Nigeria would have ripple effects on the economy. A healthy populace makes for a stronger economy.

Have you come across any rural community in Nigeria with poor health seeking behaviours because of lack of access to health services? How do you think access to health care in rural areas can be improved? Please share your thoughts in the comments section below.

Originally published at on June 6, 2019.



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Nigeria Health Watch

We use informed advocacy and communication to influence health policy and seek better health and access to healthcare in Nigeria.