Building and using evidence in health system reforms
Experience in Niger and Kaduna states
There is widespread and growing interest in designing and implementing social health insurance schemes (SHIS) across many low- and middle-income countries as a means to improve financial protection and achieve universal health coverage. SHIS have the potential to effectively help countries advance universal health coverage (UHC) — by mobilizing additional domestic resources for health, introducing essential institutional changes needed for improved health system quality and efficiency, and ultimately providing better health coverage for citizens.
The approach for the design of a SHIS is particularly important, because research suggests that variations within the key design features of SHIS may explain failure, successes, and the speed at which UHC objectives are reached. A poorly designed and implemented SHIS can have negative consequences, such as cost escalation, and limited distribution of resources to subsidize the poor and the vulnerable.
The design of the scheme
In Nigeria, Results for Development (R4D) partnered with Nigeria-based firm, Health System Consult Limited (HSCL), to provide technical support to Niger and Kaduna state governments in the design and implementation of each state’s health insurance scheme. An integral aspect of this support was building an evidence base that would inform the design of the scheme and ensure alignment with best practices and socioeconomic realties of the states.
Our shared goal was to cultivate a culture of evidence generation and utilization across both states that would be adapted not only during the design phase but also during the course of implementation.
Therefore, key government actors in each state were fully engaged throughout the process, including the scheme agency, members of the department of planning research and statistics (DPRS) in the ministry of health, scheme’s beneficiaries, and health care providers. This built ownership of key stakeholders as well as increased their capacities to implement UHC reforms.
To this end, multiple quantitative and qualitative research and analytics were conducted in each state to generate evidence. One of the first of such activities was a fiscal space analysis conducted in Niger state to identify financial constraints and explore different opportunities for state to mobilize additional funds for health, and especially for the scheme.
Furthermore, a UHC readiness assessment was conducted in both states, which enabled the identification of gaps in the states’ UHC journey and provided feasible approaches to design and implementing the scheme. The assessment: (1) presented evidence that informed decision making in the scheme design process, (2) provided recommendations on channels to provide high quality services, and (3) highlighted any additional policy and operational initiatives necessary for the success of the scheme.
The outcomes of the readiness assessments served as a foundation for conducting subsequent in-depth analyses on key design elements of the schemes in both states, including costing the benefits package and a sustainable funding analysis. The “benefits package” refers to all the health services (and commodities) that would be offered to all SHIS enrollees (often with specific details of what is to be included and excluded).
From global experience, essential benefits package tends to be the viable option in contexts with scarce resources and limited fiscal space. The states were able to cost the benefits package to help determine funding requirements for delivering basic and essential services to the population. The exercise informed the states’ prioritization and decision making regarding what services can and cannot be covered, and for what reasons. This included making trade-offs between cost-effective (value for money) options and population needs.
Findings of the benefits package costing contributed toward a broader sustainable funding analysis that compared scheme costs against potential sources of revenue to provide an evidence-based estimate of resources required to ensure scheme is financially sustainable in the long run.
Key Factors to Address Challenges of Evidence Utilization
Upon generating various sources of evidence, there were several challenges encountered in the states that, in some instances, hindered their adoption in each state.
- There was limited decision-making power of select government stakeholders who had at certain points in time lacked the legislative or political backing required. This ultimately delayed the design process.
- Political factors and interests were key elements in each state and in some cases conflicted with evidence and the legislative house.
- There was limited exchange of information, resources, and data within the agencies and across stakeholders.
- Timelines weren’t aligned and evidence sometimes wasn’t provided in time for the scheme agency to make priority scheme design decisions.
In the course of addressing such challenges, several key factors emerged as necessary to cultivate a culture of evidence generation within each state:
1. Efficient communication
This often assists to deliver a clear message in the shortest amount of time and increases chances that information will be understood and quickly utilized towards the design process. In Niger state, the R4D/HSCL consortium established a two-way communication channels through supporting the agency to develop advocacy briefs and building capacities of the Health Financing Technical Working Group (HF TWG) so that they were then able to engage with key relevant policy makers and influencers in the states (e.g. the Honourable Commissioner for Health, states Commissioner for Budget, State Secretary to the government) to advocate for allocation of resources to the scheme.
2. Understanding contextual factors
Given Nigeria’s ethnic and cultural complexities, contextual factors naturally play a major role in the design of any scheme to ensure information provided is well received by state actors. For example, in acknowledgement of certain beliefs and conceptions about insurance in both states, the consortium veered away from using the term and opted to instead use “contributory health scheme” in all communications with the state.
3. Identifying systemic challenges
Challenges around bureaucracy in politics and political will are possible factors that influence use of evidence in schemes design, therefore identifying, accounting for, and managing such bureaucracy with the use of definitive evidence from the onset is crucial. The consortium supported the agency in Niger state to set up a core implementation committee which was external to the agency and comprised of individuals with political influence within the government, who then facilitated decision making for the agency with the consortiums technical support.
4. Timeliness in the use of evidence
It’s quite important for evidence to be timely and available in time for decision making to prevent evidence being perceived as futile. Furthermore, the availability of required documents from relevant stakeholder during any scheme’s set up is essential. For this reason, the consortium trained the Niger state scheme agency staff on how to retrieve and also archive documents in time to ensure availability and utilization of resource materials in the future, when needed.
5. Full involvement and effective stakeholder management
Stakeholder engagement is essential every step of the way because this often facilitates easier acceptance and use of evidence and allows for a sense of ownership from key actors, as well as a positive dynamic and sense of unity that all are working towards the same goal. In both Niger and Kaduna state, the consortium continually involved stakeholder throughout the process and jointly worked on all aspects of the scheme design.
6. Establishing and working with a designated team
Setting up units/division responsible for evidence generation and use within a state contributory health scheme who will champion this aspect of the scheme help drive efforts forward. The consortium revitalized and strengthened the Health financing Technical Working Group (HF TWG) to play this role in Kaduna state.
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The experience with Niger and Kaduna states emphasizes the importance of ensuring necessary context-specific measures and practices are in place for timely use of evidence. Such is crucial for the success of sustainable health systems reform.
