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COMMUNITY BASED HEALTH INSURANCE (CBHI) IN NIGERIA:
PROSPECTS AND CHALLENGES.
By
Victor Eyo Assi
Department of Sociology & Anthropology
University of Uyo, Uyo Akwa Ibom state.
Email: victorassi82@gmail.com
Tel: 08037719495
&
Dorothy Ononokpono (PhD)
Department of Sociology & Anthropology
University of Uyo, Uyo Akwa Ibom state.
Email: doraon5@yahoo.com
Tel: 08104277552
ABSTRACT
One of the mechanisms for securing financial protection and achieving universal health coverage
(UHC) was identified as risk pooling, using health insurance principles to help prevent
catastrophic health expenditure by families. Failure to achieve UHC in developing countries
including Nigeria has left majority of the population without access to basic health services.
Community-based health insurance (CBHI) is currently advocated as a viable strategy to achieve
sustainable Universal Health coverage. CBHI initiatives are growing rapidly in developing
countries. For instance in Asia, it was estimated that over 7.5 million Indians benefit from about
40 CBHI programmes. The uptake of CBHI in Sub-Saharan African countries remains poor, with
the exception of Ghana and Rwanda both of which have introduced the schemes with effective
government control and support. The success of CBHI programmes in these countries, suggests
that CBHI can be a feasible option for different contexts. CBHI schemes vary a great deal in
terms of who they cover, how they cover, for what, and at what cost. Few Community-Based
Health Insurance (CBHI) programmes have been implemented in some states of Nigeria but
without much success. Health care in Nigeria is financed by a combination of tax revenue, out –
of pocket payments, donor funding, and National health insurance scheme. Nigeria's health
expenditure is relatively low, even when compared with other African countries. Thus
considering the need to achieve the sustainable development goal (SDG) which seeks to ensure
healthy lives and promote well-being for all at all ages, it is important to examine the feasibility
of CBHI programme in a country like Nigeria where the health care system remains poor. This
paper examines the prospects and challenges of implementing CBHI scheme in Nigeria.
KEYWORDS: Community Based Health Insurance, Health Care Delivery, Nigeria, Sustainable
Development Goal

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Introduction
Community Based Health Insurance (CBHI) is a model which is been regulated within Nigeria
National Health Insurance Scheme (NHIS). The uptake of the scheme has been very
disappointing. One will expect a nation like Nigeria that is ranked as one of the fastest
growing economy in the world with growth rate of 6.21 percent in 2014 from 5.65 in
2008 to solve the lingering health challenges in the rural areas and the full implementation of the
Universal Healthcare Coverage (UHC) through the Community based Health Insurance Scheme
(UNPF, 2014; NBS, 2014). Recently in 2014, the country’s Gross Domestic Product (GDP)
was rebased, making it the largest economy in Africa, with a GDP of US $510billion.
(NBS, 2014). The 2000 world health report of the World Health Organisation (WHO)
have shown that Nigeria’s health system needs improvement. World Bank (2013) opined
that the life expectancy of 52 years is below the Sub -‐ Saharan Africa’s average (56
years). Infant mortality rate is 39 in every 1,000 live births, under - five mortality rate is
124 in every 1,000 live births, while maternal mortality rate was estimated at 630 (2010
figure) in every 100,000 births (The World Databank, 2012).
One key factor is the country’s poor budgetary allocation to health, which has in the
past years hovered around 5 - 6 percent of total annual budget, and falls short of the
15% (US $14/N2, 268 per capita expenditure on health) expected of a developing
country in order to achieve the World Health Organization’s recommendation for
optimum health coverage by 2015.The total health expenditure as a percentage of GDP
has not been consistent. Increased expenditure caused by the need to cope with injury and
illness has been identified as one of the main factors responsible for driving vulnerable
households further into poverty (WHO, 2000).
Meghan (2010) opined that more than half of health expenditure in poor countries is covered by
out-of-pocket (OOP) payments incurred by households. An increase in such expenditure can
have catastrophic effects and may deplete a household’s ability to generate current and future
income and have inter-generational consequences as households may be compelled to incur debt,

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sell productive assets, draw down buffer food stocks, or sacrifice children’s education. Foregoing
medical care may lead to long lasting illness, disability or even death (O’Donnell et al., 2005; De
Weerdt and Dercon, 2006; Flores et al., 2008).
Community-based health insurance (CBHI) is a not-for-profit mechanism based upon solidarity
among a relatively small group of people. CBHI schemes vary a great deal in terms of who they
cover, how, for what, and at what cost. The majority of CBHI schemes operate in rural areas, and
their members are relatively poor. They are regarded as “local initiative which is built on
traditional coping mechanisms to provide small scale health insurance products specially
designed to meet the needs of low-income households ’’ (Carrin et al as cited in Mugisha and
Mugumya 2010, 181).
To Churchill, (2006) community-based health insurance is an outline of insurance that protects
low-income people against specific disease in exchange for regular premium payments balanced
to the likelihood and cost of the risk concerned.” In the prospect of this, the need arises for the
government to put in motion policies and patterns that will advance the employment of
community health insurance scheme. “According to Rosenthal (2001), rural dwellers may be less
disposed to seek health services owing to the growing costs of medical services if the integrated
health insurance system as set up by the province.” CBHI is also considered as any program
managed and operated by a community-based organization, other than government or a private
for-profit company, that provides risk-pooling to cover the costs (or some part thereof) of health
care services. Beneficiaries are associated with, or involved in the management of community-
based schemes, at least in the choice of the health services it covers. It is voluntary in nature,
formed on the basis of an ethnic of mutual aid, and covers a variety of benefit packages. CBHIs
can be initiated by health facilities, NGOs, trade unions, local communities, local governments
or cooperatives and can be owned and run by any of these organizations (Jutting,(2004) in Tabor
2005).
In Nigeria, households bear the highest burden of health expenditure. A study carried out by
Olakunde (2012), revealed that health financing system is largely characterized by low
investment by the government, extensive out – of - pocket payments, limited insurance coverage,
and low donor funding. Obviously, out –of - pockets account for the highest proportion of health
expenditure in Nigeria. Out – of - pocket expenditure constituted the larger proportion of total
health expenditure averaged 64.59% from 1998 to 2002 (Soyinbo, 2005). In 2003, it accounted

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for 74% of total health expenditure. It decreased to 66% in 2004 and later increased to 68% in
2005 (Soyibo, Olaniyan & Lawanson, 2009). Since most Nigerians depend on their pockets to
utilize health services, the low income groups such as the unemployed, poor, disabled, youths,
housewives and illiterates are usually victims of circumstances leading to low patronage of
health facilities when they need treatment from ill - conditions. This has contributed largely to
the poor health indices in Nigeria especially in areas of maternal and child mortality, HIV/AIDS,
tuberculosis and life expectancy which obviously threaten the achievement of MDGs targets. It is
pertinent to state here that, to achieve a sustainable developed national, its citizens health must
be put into consideration and implemented because a nation with high mortality rate will never
experience sustainable development especially those in the rural areas.
Health insurance encompasses risk-sharing. It is supposed to reduce unforeseeable or even
unaffordable health care costs (in the case of illness) to calculable, regularly paid premiums. But
in Africa, public and private health insurance cover almost exclusively the formal sector, and
therefore achieve a coverage rate of no more than 10 percent of the population. The majority of
African citizens – informal sector workers and the rural population – don’t have access to this
kind of social protection (World Bank, 1994). As a response to the lack of social security, the
negative side-effects of user fees and the persistent problems with health care financing, various
types of community financing, especially for urban and rural self-employed and informal sector
workers, have been recently proposed as a way forward (WHO 2001).
OVERVIEW OF COMMUNITY BASED HEALTH INSURANCE SCHEME
Universal healthcare coverage (UHC) has been difficult to achieve in many developing
countries, especially Nigeria, with large populations remaining over-reliant on direct (out-of-
pocket, OOP) expenses that include over-the-counter payments for medicines and fees for
consultations and procedures (WHO, 2010). The World Health Organization (WHO) views
medical fees as a significant obstacle to healthcare coverage and utilization, and has stated that
the only way to reduce reliance on direct payments is for governments to encourage the risk-
pooling prepayment approach (WHO, 2010). It’s on this ground, community-based health
insurance (CBHI) emerged as an alternative for members in low income families. CBHI schemes
are designed to ensure that sufficient resources are made available for members to access
effective health care (WHO, 2000). It is difficult to find up – to – date details of schemes

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currently running in Nigeria or recent national estimates of participation rates. Community-based
health insurance system is an emerging scheme designed with the exclusive purpose of
improving access to quality health services for low-income rural families who are excluded from
the National Health Insurance Scheme.”
Sound health is necessary for the health of the rural inhabitants. Sound health is similarly
required for economic and societal growth (World Health Organization, 2000). “Workers have to
be good for them to cultivate, and kids have to be healthy to attend school and partake in other
actions.” Inadequate health facility is regularly related to disease and injuries among the rural
inhabitants. At the same time, poor health has another critical impact: it causes poverty, in that
large health expenditure can bankrupt families. (Garba, Ibrahim, Azhar Harun et al, 2015).
According to WHO (2000) the main causes of poor health are insufficient prevention and lack of
practical access to primary health maintenance, along with inadequate nutrition and impure
water. While health-related poverty consequences beginning a lack of risk pooling and insurance
Underfunding of healthcare by government and private organization are key to both of these
negative effects. Furthermore, many African countries especially Nigeria compounds these
problems by making inefficient use of the resources they have for health care and risk pooling.
The results could be required through the utilization of the workable health insurance program
that can improve the well-being of the rural inhabitants.
Metiboba reported in 2011 a statement made in 2009 by Audu, the Secretary for the NHIS, that
only 3% of the entire Nigerian Population was covered. (Metiboba S, 2012). Underlying
problems have been reviewed more recently by Baba and Omotan, who place the poor
performance of Nigeria’s NHIS within the wider context of fragmented approach to healthcare
that involves both Federal and State government, deterioration in the public health service caused
by a “brain drain” and lack of resources and the high levels of poverty encountered in Nigeria.
(Baba & Omotara, 2012).
According to the World Bank, a number of Community Based Health Insurance Schemes
(CBHIs) are growing rapidly; however, they caution that many schemes do fail (Tabor 2005, 5).
John Ataguba (2008) argues that. Many African countries, including Nigeria, Tanzania, Kenya,
Uganda, and Cameroon have community-based health insurance schemes that offer protection

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for the poor but are unsustainable because poor people can't contribute enough premiums to
maintain the schemes (Appiah, 2012).
CLASSICFICATIONS OF COMMUNITY BASED HEALTH INSURANCE SCHEME
Classification of Community Based Health Insurance can be done in several ways in accordance
to the kind of benefit provided, circumstances of their creation, and levels of risk pooling,
management and ownership, irrespective of their class, they all possess some level of similarities
such as voluntary membership, prepayment of contributions and entitlement to specific benefits.
The scheme is design as not – for - profit making in all ramifications. CBHI schemes are noted
for the principal role of a community involvement in raising funds, pooling (accrued prepaid
healthcare funds on behalf of a population (Kutzin, 2001), allocation of funds, purchasing
(Mclntrye.D, 2007 & Kutzin, 2001), and supervision of healthcare financing arrangement.
CBHI is the application of insurance principle by the community in conjunction with NGOs,
healthcare providers which is solely directed by their community choice and is based on their
arrangement and structures. These schemes originated on the basis of an ethnic mutual aid,
collective pooling of health risks and solidarity in which members participate efficiently in its
functioning and management. It is voluntary, autonomous, and not – for – profit organisation.
Payments are collected by community in advance of treatment and this is managed in paying for
providers. (Atim, 1998).
TYPES OF COMMUNITY BASED HEALTH INSURANCE FINANCING SCHEMES
There are three major types of community based health financing schemes namely:
i). Community prepayment health organizations
ii). Provider based health insurance
iii). Government – run but community – involved health insurance.
These schemes differ in terms of its design and the involvement of the community in setting it
up, mobilization of resources, its management and supervision.
i. COMMUNITY HEALTH PREPAYEMENT SCHEME:
These types of health organizations are characterized by voluntary membership and payments are
made in advance in order to cover potential medical costs. Members of the schemes pay

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premiums on a regular basis, usually when their incomes are high. Such schemes are often
initiated with the technical and financial support of NGOs and thereafter the community takes
full responsibility for administering and managing the scheme. Local governments may also play
a role in encouraging and supporting the efforts of such schemes. The community participates in
designing the scheme and decides on the level of benefit and the corresponding premium. In
addition, members participate actively in the administration and supervision (Arhin-Tenkorang,
2001). While community involvement is a purported strength of this approach it is also a
weakness as the establishment and continuity of such schemes depends on social solidarity and
trust amongst community members. (The National Health Insurance Scheme). Poor
management and accounting skills may also undermine the sustainability of such schemes.
ii. PROVIDER BASED HEALTH INSURANCE:
These types of health insurance schemes are initiated by healthcare providers (such as a town or
regional hospitals) to encourage utilization of healthcare services. This review contains seven
studies which may be placed under this rubric. The schemes mainly cover expensive inpatient
care and hospitals and may have recourse to external funds to subsidize service costs. In this
framework, the health care providers are responsible for mobilizing resources and providing
health care services. The role of the community in designing and administering the scheme is
limited. However, members of the schemes are given a chance to participate in scheme
supervision and provide feedback on service quality through meetings organized by the health
care providers. Such schemes are often restricted to those households living in the catchment
area of a health facility (Arhin-Tenkorang, 2001).
iii. GOVERNMENT RUN COMMUNITY – INVOLVED HEALTH INSURANCE:
Government run community-involved health insurance schemes are often linked to formal social
insurance programmes with the objective of creating access to a universal health care system
(Jakab and Krishnan, 2001). Unlike other models, government initiated schemes often cover both
basic curative and impatient care. The government (national or regional) plays a substantial role
in initiating, designing and implementation of such schemes (Arhin-Tenkorang, 2001). The
participation of the community in such schemes varies substantially across countries. Some
governments create conditions which enable community involvement in defining the benefit
package, setting of premiums and scheme management while others introduce the schemes in a

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top-down manner and limit the role of the community. Membership in such government-initiated
health insurance may not always be voluntary. Twenty five studies in this review fall in the
category of government-run models of community health insurance schemes. (Isaac A, 2014)
Unlike other forms of CBHI, government supported health insurance schemes have the potential
to reach a relatively large number of households. Governments in co-operation with donor
agencies may provide reductions in premium and fee waivers for the poorest segments of society
while retaining a universal benefit package. The disadvantage of these schemes may lie in their
design and implementation features. Since such programmes are the result of a top-down
approach, they may not be sensitive to local needs. Limiting the role of community participation
in awareness-raising, decision-making and supervision probably robs such schemes of a sense of
ownership which in turn may hamper sustainability.
THEORETICAL FRAMEWORK
There are many theories developed by different scholars that can be used in explaining CBHIs,
but for the purpose of clarity, social mobilization Theory and social capital theory was
adopted for the explanation of CBHIs, even though CBHIs is not functional in the country
(Nigeria).
Social Mobility Theory:
Social mobilization theory has been proven as effective for health promotion especially when people
are reluctant to respond positively to health programme. In the case of CBHI, people need to be
mobilized in order to understand and to adhere to the program given the fact that most of people do
not see direct benefits of health insurance (time inconsistence problem). Hence, this section develops
social mobilization theory and shows how it leads to social and behavior change through effective
communication. Social mobilization is a multi-level, dynamic approach that can be initiated either
top-down or bottom-up. Community is perceived in its broadest sense to include all those who have a
role and responsibility in effecting change. As information is made available and understandable to
both experts and lay people, broad ownership and popular support are created (Russel and Levitt-
Dayal, 2003).
Social mobilization refers to “the use of planned actions and processes to reach, influence, and
involve all stakeholders across all relevant/pertinent/involved/concerned sectors, including the

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national and the community level to raise awareness, change behavior, change policy, demand a
particular development programme, or reallocate resources or services. The social mobilization
approach can be used in different health issues including safe motherhood, community based health
insurance, family planning, HIV/AIDS prevention, girls education and so on.
A community based health insurance like any other health program, to be effective, needs a multi-
pronged approach of social mobilization that encompassed communication through dialogue at
multiple levels and among multiple audiences. It also requires broaden public support through
community mobilization. Here Community mobilization refers to a process of problem identification
and problem solving stimulated by a community itself or facilitated by others that involves local
institutions, local leaders, community groups and members of the community (CEDPA, 2000).
Community mobilization uses deliberate, participatory processes to involve local institutions, local
leaders, community groups, and members of the community to organize for collective action toward
a common purpose. Community mobilization is characterized by respect for the community and its
needs.
For social mobilization to be successful and to build this base of popular support, communication
needs to be a process of dialogue, information sharing, mutual understanding, and collective
action. Standardized messages are used to promote a dialogue within the community as a whole
(Aubel, 2001). It should also be noted that the CBHI to be sustainable needs mobilization for
human and financial resources. Neil McKee (1992) lists five main approaches to mobilizing
human and financial resources: (1) political mobilization, (2) government mobilization, (3)
community mobilization, (4) corporate mobilization, and (5) beneficiary mobilization. Social
mobilization uses community events to attract the attention of policy makers, community
members, and media representatives and motivate them to take action on a specific issue such as
immunization, literacy, or family planning. Social mobilization amplifies advocacy activities,
strengthens communication, and allows many more societal partners to participate in the
program. To be successful a CBHI program needs to use all those approaches to mobilize human
and financial resources.

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Social capital theory:
Putnam (1993), the first scholar to popularize social capital theory, argues that social capital
consists of “features of social organization such as networks, norms, and social trust that
facilitate coordination and cooperation for mutual benefit” (Putnam, 1993). He asserts that
informal networks of civic engagement build social capital which in turn facilitates improved
governance. Michael Woolcock takes the theory a bit farther by breaking social capital into four
categories: (i) bonding social capital inhering in micro level intra-community ties; (ii) bridging
social capital inhering in micro level extra-community networks; (iii) bridging social capital
inhering in relations between communities and macro-level state institutions; and (iv) bonding
social capital inhering in macro level social relations within public institutions (Maldovsky and
Mossialos, 2006).
According to Woolcock and Narayan (2000) social capital helps the poor to manage risk and
vulnerability. Thus, CBHI which aims at managing risk and vulnerability may be well accepted
by a community that possesses a high stock of social capital. A high level of social capital is
associated with a high level of altruism among individuals; this makes it possible to take into
consideration the well-being of other members of the group. The presence of social capital
always has a positive effect on a community’s welfare. Fukuyama (1995) asserted that “social
capital can be defined simply as the existence of a certain set of informal values or norms shared
among the members of a group that permit cooperation among them. Sobel (2002) describes
social capital as circumstances in which individuals can benefit from group membership. Thus,
social capital refers to social life networks, norms, and trust that enable households to act
together more effectively to pursue shared objectives. This social capital in the community can
be an asset for the breakthrough of CBHI, thus contributing to the demand for CBHI at the
community level.

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Due to the nature of CBHI schemes, their success therefore depends largely on the existence and
survival of social capital in the community. CBHI can therefore attain sustainability,
effectiveness and be long-lasting with the help of social capital in a community; because social
capital has a positive influence on the community demand for insurance (Donfouet HPP,
Mahieu, 2012).
More so, evidence has shown that social capital18 acts positively on the value people attach to
their health. Weak level of social capital amongst members of a group results in an increasing
risk of experiencing self-centered behavior at its peak of anti-selection and moral risk
(Mladovsky & Mossialos, 2008). On the other hand, high level of social capital affects
households’ decision on health insurance which in turn increases the demand for CBHI
(Donfouet & Mahieu, 2012). As shown in table 2 below:
Table 1: Social capital and network links
SOCIAL CAPITAL
1. Network Links
Between different communities (vertical) and similar communities
(horizontal)
2. Community Links
Between extended families clubs, local organizations, civic groups and
Association
3. Societal links
Between government and citizens via community participation and public -
private partnerships
4. Institutional Links
To communities, legal, political and cultural environments
Source: Preker et al 2002
Figure 1: Generic conceptual framework for analyzing uptake of CBHIs
D*
C*
B*

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Sources: Adebayo, 2014.
Key to framework
A* – Fundamental factors evolving around uptake of community based health insurance
Socio-demographic factors: age, sex, geographic location, education, marital status, head of
household, household size, employment status, wealth quintile and membership of an
association.
Health related factors: illness experience, state of health, utilization of health facilities, and
quality of health services, availability of drugs and medical supplies and health care workforce
Other factors: Trust, relationship and distance to health facilities.
B* – Characteristics of the scheme (managerial, technical, institutional)
Dimensions of programmes and Social capital scheme (political, economic, managerial and
social).
C* - Role of government (subsidies, policy framework and implementation, technical support)
Role of community (ownership and support).
A*

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D* - Social protection.
CHALLENGES OF COMMUNITY BASED HEALTH SCHEME
The scheme has not been visible in Nigeria and its uptake has been faced with lots of challenges.
The major challenges are: Fraud and corruption, Management Capacity, Poor Awareness, Poor
services, Poor Incentives, Attrition (withdrawal or loss members) and Payment of Premium.
Management Capacity:
A weakness in management capacity is one of the most severe problems faced by the CBHIs. The
weak CBHI management capacity includes a failure to adequately manage insurance risks, unrealistic
premiums, the absence of a community business culture, low controls for fraud, limited coverage
(and hence high risk of adverse selection), absence of qualified staff trained in insurance, lack of
marketing surveys to link products to perceived needs, limited marketing beyond the pilot phase,
poor data handling and management capacities, and stiff competition from highly subsidized
government hospitals and national social health insurance agencies ( McCord and Osinde 2002;
Musau, 1999).
In practice, many CBHIs have managers who are not well-versed in insurance, finance, or in the
basics of business management. That is because CBHIs are managed on a voluntary basis and draw
on existing members as elected managers. McCord argues that weak management can lead to the
rapid erosion of trust. It is one of the main reasons given for the demise of new schemes (McCord,
2002). Banerjee and Duflo added that the lack of trust leads to another problem of lack of credibility
on the insurance provider. Credibility is very crucial for the insurance provider because the insurance
contract that the insurer enters in with the insured requires the individual who is to be insured to pay
in advance. This means that the insured individual is required to trust the insurer completely. Hence
lack of credibility becomes a huge problem especially when insurance companies are unable to
address clearly the problem of fraud or when the nature of the products is unclear (Banerjee and
Duflo, 2011). Management information systems –manual or computerized –are also critical to the
effective operation of a CBHI. It becomes extremely difficult to manage a program without the
ability to track premium payments, utilization, and other costs. Integrating hands-on management
controls with information systems can help CBHIs cut costs and improve service
According to Tabor, there are different problems related to the context in which CBHI is designed
and implemented, such as poverty, awareness, and covariate risk (Tabor, 2005). CBHIs become
successful when the context in which it has been designed, and in which it is being implanted, is

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favorable. In case that context is not good, the design and the implementation of the scheme are also
somehow negatively affected.
Payment of Premium:
Severe poverty can slow down the success of a CBHI. If most people are simply struggling to
survive, they will be less willing to pay insurance premiums in advance to use services at a latter
point in time. In fact the poor are the most vulnerable in a society because they are the most exposed
to the whole range of risks and at the same time they have the least access to appropriate risk
management instruments. The poor have only recourse to coping mechanisms: they try to cope with
the risk when it has already occurred (Holzmann & Jorgensen, 2001). Besides money, payment
modalities can also present problems. If the annual premium must be paid in a lump sum (instead of
payments spread out over the year), households find it more difficult to pay.
According to Morestin and Ridde ( 2010 ), in Burkina Faso, for instance, the households stressed that
a single payment is more problematic in rural areas, where it is hard to obtain credit. Another element
is the time at which the payment is due. Incomes of workers in the informal or agricultural sectors
vary over the course of the year. Apart from the problems related to poverty, there is also another
problem of awareness. There is an argument that most of the time the poor do not understand the
concept of insurance very well. It is true that insurance is unlike most transactions that the poor are
used to. It is something that you pay for, hoping that you will never need to make use of it (Banerjee
and Dulfo 2012). Cultural norms and values also play a role. If people see disease as a punishment
for evil behavior, they will not join a CBHI. In some parts of rural Benin, for example, saving money
for a disease was seen to be “wishing oneself the disease” (Tabor, 2005). Tabor also argues that
under-insurance, or the choice of an individual to buy less insurance than is needed or could be
afforded, can occur when people don’t understand the benefits that insurance can bring. Drop-out
rates can be very high in cases where individuals feel that the benefits should correspond to the
contributions they have made (i.e. savings concepts).
Fraud and corruption:
Corruption is a disease that eaten into the fabrics of Nigeria economy and developmental process.
Fraud and corruption are among the major problems that hold back the implementation of CBHI
schemes. Health insurance is subject to the risk of fraud, or deceptions intentionally practiced by
patients, providers, and CBHI staff and managers, to secure unfair or unlawful gain (Tabor, 2005
p.39). McCord and Osinde (2002) argue that lack of professional management can make CBHIs
vulnerable to fraud. In the case of Tanzania’s UMASIDA CBHI, group leaders were selected from

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the local communities. They were not professional managers, yet they had a great deal of financial
responsibility. Several of them became frustrated with all the work involved and found
themselves tempted by the premiums. Hence, many of these groups experienced a change in
leadership because of fraud (McCord & Osinde, 2002).
Apart from the fraud on behalf of mangers, cases of fraud on behalf of patients have been reported by
the CBHIs managers at different health facilities in Rwanda. Normally, new subscribers had to wait
one month before enjoying their contributions. At times, however, they did not want to respect that
period and, as a result, wanted to corrupt CBHI managers in order to get treatment before the due
date. Until we start having a right frame of mind towards achieving success especially when it comes
to handling of money for the execution of projects, we will never get it right and will also remand the
way and stage we are today.
Attrition (withdrawal or loss of members):
Loss of members, either voluntarily or due to other reasons, has been a key deterrent to the
coverage and success of the scheme. It has been difficult to retain them, and this has been
attributed to poverty and inadequate information on the scheme. Participants, especially the
poor, may sometimes find it challenging to consistently pay premium monthly and even
harder to pay the accompanying fines (as in case the Ikosi -‐ Isheri scheme); as a result
there are too many inactive members in the scheme.
There is Still Poor Awareness:
These are key factors responsible for the current state of the scheme, though there have
been some effort to create awareness. Sadly, these campaigns have not been consistent,
though little is still being done during antenatal and immunizations visits. The people
should be probably informed and educated about the programme and its benefits. Until that is
done the Universal Health Coverage will be unachievable.
Lack of Support from the Local Government:
The scheme has not benefitted tangibly from the local government. One reason attributed
to this was that the local government or its representatives were not involved in the

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planning, design and implementation of the scheme, a suggestion that the scheme is
being politicized.
Poor Services:
Poor services have also been noted to be a deterrent to patronage , especially among
members who truly understand the scheme, but apparently were not satisfied with the
services rendered by the provider.
Poor Incentives:
The scheme still suffers poor incentives for the managers (board of trustees) the management
however should tries to compensate members with little incentives as sitting
allowance. So as to encourage and motivate them to stay and render the necessary services.
CONCLUSION / RECOMMENDATIONS
This study has justify its self by reviewing Community Based Health Insurance Scheme in
Nigeria, the types and have been able to apply Social Mobilization Theory and social Capital
Theory to explain the challenges and prospects of Community Based Health Insurance in Nigeria
and other African countries.
Conclusively, for the program to be successful, all noted challenges must be addressed. There
should be incentives for the BoT ( the workers), either as salary or other benefits. Also,
it must be free of politics or engaging politicians in the management of the scheme. The
success of the CBHIS and its ability to achieve its goals including achieving UHC in
Nigeria depend greatly on the sustainability of the program and the ability to scale it
up. Ownership, political will, local leadership, as well as motivation and building trust
in the people have been identified as key factors for the success of the program.9
This study is not exhaustive; more still needs to be done in terms of research in order to
develop a robust study report. First, perception and satisfaction surveys are necessary to
understand people’s opinion, knowledge, and use of the program. Also, there must be
well planned and well implemented monitoring and evaluation programs . The findings
from these processes will not only help churn out vital statistics, they also will help
promote the sustainability of the scheme so as to achieve a sustainable development Goal.
The findings from this study further necessitate the following recommendations that will help to
improve the programme in the country if been implemented by the policy makers:

17. 17 | P a g e
i. Program design should be community specific. By this, each community must be seen as
unique with its own characteristics, though may share similarities with other.
Socio- ‐ demographic factors such as income status and socio-‐ economic status
of the people must be taken into consideration. As a result, the
implementation of the scheme in that community must share the observed
characteristics.
ii. Increased awareness among community members in all Local Government
Areas. This is necessary and may take the form of community awareness
campaigns or other means such as use of print and electronic media and to
encourage participation, promote ownership among community members and
mobilize resources, there be should community engagement and advocacy visits
to stakeholders in the community.
iii. The services provided must be of quality and deliver in a manner that meets the
needs of the users. This is necessary to build trust and confidence in the system.
This will encourage users to pay premium in timely manner, knowing that they
will get the benefits in the future of a payment today. It will also encourage
them to invite others to use the scheme.
iv. This scheme should be devoid of politics such as party partisanship,
nepotism etc. Local government must be engaged appropriately, irrespective of
political differences or affiliations.
v. Coverage is very low and may take many years, beyond the 2015 goal to achieve
universal health coverage in Nigeria. There is still a lot to be done as majority of
the members either drop out or remain inactive due to couple of reasons, either
because they could not afford continuity of renewing premium or not benefitting

18. 18 | P a g e
from the services as thought they would. A further research would be
beneficial in this respect.
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