Over 1.3 billion people around the world live below $2 a day – 91 million of those people live here in Nigeria. Poverty means vulnerability, and when combined with poor health, it can have devastating consequences. When you consider that people living below the poverty line also face a disproportionate propensity for illness, the picture becomes even more dire and urgent.
When poor people fall sick, the inability to pay for treatment can result in the preventable loss of life. This is especially true for people with sickle cell anaemia, who routinely fall sick. Nigeria is recorded to have the highest prevalence of sickle cell disease across the globe – every year, 150,000 children are born with the disease, and with nearly 50 percent of the nation living in extreme poverty, it is clear that a significant portion of this group are from low-income households. Sickle cell comes with numerous serious medical complications and often requires a wide array of serious medical interventions inhibiting the sufferers from working, further affecting their financial ability to access healthcare.
In my capacity as the founder of the Samira Sanusi Sickle Cell Foundation, I provide a safety net, covering the cost of medication and hospital treatments for low-income families living with sickle cell. I am almost always a last resort for people who have nowhere else to turn.
People like Asiya, a young woman living with sickle cell in a small village in Katsina State. Even though her husband owns and runs a local farm, both Asiya and her husband are financially excluded – they do not have bank accounts and the little income they make is used for food and shelter. Every time Asiya falls ill and needs to be admitted to the hospital, she has to get in touch with the Foundation through relatives – a process that can take time. If Asiya is ever in a life-threatening situation, the time it will take for her to access the funds to pay for the critical care required may mean that Asiya will die. An hour or two could literally be the difference between life and death.
Even though it may not seem like it, Asiya is one of the lucky ones – she has a safety net in the Foundation that many low-income families do not. While we help where we can, the Foundation’s net cannot cover everyone and many people are often left without the help they desperately need to access healthcare.
The costs of healthcare can be prohibitive to its access. How can we democratise access to basic healthcare so that the lives of people like Asiyaare not hanging in the balance? How can we ensure that there are basic health care provisions for people who have no access to a safety net like the Samira Sanusi Sickle Cell Foundation, but need health care? How do we reduce the number of preventable deaths, incidents of people’s loved ones dying because they are unable to afford the health care required to save their lives? These are the questions that keep me up at night – questions I know we must find answers to if we are to increase the quality of life for millions of Nigerians across the country.
The healthcare structure in Nigeria is heavily weighted towards the private sector, with private healthcare being the predominant form of healthcare delivery over the last decade. About 66.8 percent of services are offered by private practitioners, and only 33.2 percent offered by public practitioners. Even where the provider is a public practitioner, there is often a cost for services which can be beyond the affordability threshold of low-income families.
One particular method, which I have become a strong advocate for, is health-focused savings; though it can be challenging, especially for low-income individuals, targeted savings plans can contribute to preparedness for health-related shocks and increase the likelihood of a positive outcome.
In Burkina Faso, health-specific savings accounts have proven to be an effective method for poorer populations to increase their financial preparedness for the medical expenses associated with health shocks, should they occur. Réseau des Caisses Populaires du Burkina (RCPB), a federation of credit union networks, the largest microfinance institution in Burkina Faso, offers a voluntary health savings product whereby clients agree to deposit a set minimum amount of at least $1 per month into a special account devoted only to health expenses. The client will only have access to the funds upon presentation of health expense proof such as a receipt or doctor’s form specifying treatment. Here in Nigeria, as it relates to sickle cell sufferers, this may mean that they are able to access critical care when they are in “crisis”, thus safeguarding their lives.
Even more so, financial products like health insurance have the potential to help families avoid the catastrophic consequences of health shocks but most private health insurance products cost too much to be truly inclusive. This is evidenced by the fact that In Nigeria, at least 90-95 percent of the population do not have access to health insurance coverage and over 100 million Nigerians cannot afford to pay bills for treatment of illnesses in public health facilities. Health insurance products need to be affordable so that people at the bottom of the pyramid – the very people who need it most – can benefit from it. Additionally, the routine exclusion of pre-existing conditions like sickle cell by traditional insurance providers means that many sickle cell sufferers like Asiya would be unable to benefit from traditional insurance products, even if the cost barrier was sufficiently addressed.
The Nigerian National Health Insurance Scheme (NHIS) was established under Act 35 of 1999 by the Federal Government of Nigeria to provide access to health care to Nigerians at an affordable cost. The scheme includes packages which sickle cell sufferers can benefit from, albeit not in a comprehensive way. The Vital Contributors’ Social Health Insurance Programme (VCSHIP) is a low-cost package designed for individuals who do not belong to an NHIS community. It costs N15,000 per annum and covers the cost of access to basic medical services like blood work and medication.
Even though the NHIS has the potential to deliver a sustainable healthcare financing framework for Nigeria, the scheme, which officially launched in 2005 (six years after the establishment of the Act), has so far failed to deliver against its main objective – to make healthcare accessible to all Nigerians, with only 3 percent access directly attributable to the scheme. A lack of political will is the main reason for the failures of the scheme in Nigeria, exacerbated by a lack of government funding, existing limitations on which the scheme was founded, as well as poor implementation. There are many lessons that can be gleaned from the last decade and a half, but how can we apply these learnings in a way that reaps dividends for the millions of Nigerians currently left without access to health care?
The reality is that sickle cell patients are guaranteed to fall ill – and sometimes in ways that are life-threatening. Even with the type of basic cover currently being offered under the NHIS (and which the vast majority of people are not covered by), sickle cell patients will still be left without care should they have a “crisis” or fall seriously ill. There is a need to explore alternative forms of comprehensive healthcare financing that can deliver the access to healthcare required to safeguard against preventable loss of life.
There are many examples from other developing countries like India, China and the Philippines who have mirrored the models created by more developed countries like Japan in offering social health insurance. Success rates have varied, but a critical factor is that the quality of the policies and regulatory frameworks on with these health initiatives are built have a direct impact on their success rates. With regard to pre-existing conditions, in some countries, waiting periods are imposed while the extent of a patient’s needs is reviewed and assessed ahead of providing a package to accommodate their peculiar needs.
Health insurance in some form is the key to democratising access to health services across Nigeria, but in a country where 91 million people are living below the poverty line; where 60 percent of people are financially excluded and don’t have bank accounts; and where up to 3 percent of Nigerians (up to 6 million individuals) suffer from sickle cell disease – we must be innovative in creating inclusive health-related financial products and combine these products with the education required to ensure that their benefits are understood.
However, it has taken a significant amount of time to get to a point at which basic packages are being made accessible to those with pre-existing conditions, there is a potentially long lead time between now and the existence of a robust enough package to cover the financial impact of health crises. This reinforces the importance of saving and savings tools which enable those people who suffer from sickle cell disease to have a buffer for the management of health shocks.
I am optimistic that the digital and technological advances we have seen in recent times are opening up more opportunities for the intersection of financial inclusion and health agendas – an intersection that will amplify the impact of these interventions for everyone, especially people living with sickle cell.
Sanusi is founder, Samira Sanusi Sickle Cell Foundation.