Stakeholders’ Values and Power Dynamics and Relations in Community Based Health Insurance: Evidence from Anambra State Nigeria.

Abstract

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 high costs of seeking medical care and treatment for illness. CBHI was piloted in Anambra State in Southeast Nigeria in 2003 as a way of increasing the provision and utilisation of health services. This study set out to identify the factors that influenced the development and implementation of the scheme. The study was conducted in 2006-2007 and compared the experiences of two communities two communities judged to have different levels of success in implementing CBHI, in terms of community involvement and support for the scheme and levels of enrolment. It involved document reviews, In depth interviews with state and local level policymakers, managers, health workers, and members of Community Health Committees. In addition, 8 Focus group discussions with members and non-members of CBHI were conducted. The result showed that the development and implementation of the CBHI followed a period of political transition with the introduction of a new State Governor who aspired to improve access to quality health care and who was personally responsible for driving the policy forward at rapid pace. Several factors affected the implementation of the scheme in the two case-study locations namely: relations between state and local government authorities; community support and participation; power dynamics between community actors; health workers attitudes towards the scheme and parallel drug acquisition and delivery systems. In implementing new health policies, effort should be made to secure widespread backing among groups (both within and outside the Ministry of Health) with the power to sustain implementation; include local actors who can either sustain or block implementation in the development of new policies in particular health workers; take into consideration power dynamics between local community actors when designing policies that will be implemented at the local-level and ensure that policy guidelines are clearly communicated to those responsible for implementing the policy and to community members.