In 2020, the Kwara State Government, launched the Kwara Health Insurance Scheme (KHIS) to make access to basic healthcare by Kwara indigents seamless. The program however hasn’t been entirely flawless. In this report, Omolola Afolabi unravels some of the inadequacies bedeviling the scheme in the state.

For Sanni Amuda, a 46-year-old artisan in Awodi Gambari, Ilorin, the past few years have been akin to sprinting through the fog. His income has been irregular whilst also struggling with meeting his family’s needs.

He recalls a watershed moment when the government announced the commencement of the Kwara State Health Insurance Scheme (KHIS). He said he felt he could save funds and take care of his wife and four children’s medical needs by subscribing to the scheme but he soon met a brick wall of challenges.

“I was so excited about the scheme as I thought it would make access to quality healthcare for my family and I easy and affordable. I went with my wife and four children and after a long, stressful day of queuing up to register, we eventually got all our names and passport photographs captured. They promised to call me soon to pick up our cards but till this moment, they have not communicated that to me.”

Sanni Audu

Amuda who works as a carpenter has seen his enthusiasm give way to disbelief. He says the scheme is a scam. He was vehement.

The scheme allows for a maximum number of six persons to enroll from each family but it’s been six months since Amuda registered his family without any official proof.

A scheme blighted with challenges

The Kwara State Health Insurance Scheme was established by law in November 2017 to provide mandatory health insurance coverage to all residents of Kwara State, particularly the indigent people amongst its burgeoning population of 3.2 million people.

The insurance package provides coverage for consultations, diagnostic tests, and medication for all disease categories, including hypertension and diabetes, that can be managed at a primary health care level and limited coverage of secondary care services.

Secondary care services provided include radiological and more complex laboratory diagnostic tests and hospital admissions for different disease categories, minor and intermediate surgery, antenatal care and delivery care, neonatal care, immunizations, annual check-ups and HIV/AIDS treatment care support.

Excluded from the program are high technology investigations (computed tomography and magnetic resonance imaging), major surgeries and complex eye surgeries, family planning commodities, treatment for substance abuse/addiction, and cancer care requiring chemotherapy.

According to Governor Abdulrahman Abdulrazak in 2021, about 30,000 people have registered under the scheme with only 5 per cent benefiting from the scheme. The scheme, according to Kwara indigents and residents who spoke with Solacebase has been fraught with several problems right from its inception. The inadequacies are seen in the poor rate of adoption and utilization of the scheme by the people.

Amuda added that despite being an indigent in Kwara, he still spends a significant part of his meagre earnings on healthcare for his family. The scheme, touted by the Abdulrazak-led administration in different quarters as a novel initiative, has become a shadow of its projected promises.

A Kwara indigene, Falilat Ajoke, said she had enrolled for the scheme 3 months ago and has been left in the dark with no response to her enquiries.

“I have had some health challenges for a while now and it would have been better managed if I was able to get information from the designated quarters. Because of my state of pregnancy, I looked forward to accessing the services but when their contact number was not reachable, my only resort was to consult traditional and private facilities.”

Faliat Ajoke

Mrs Falilat Ajoke has dialed the number designated for calls severally by the KHIS without any response .

Ajoke reiterated that the contact numbers of the scheme were not reachable when she and her friends attempted to reach the agency for enquiries without success. Attempts by Solacebase to reach KHIS via its contact numbers on 08148831004, 09024770622 were futile. Calls placed to the numbers didn’t connect.

The Scheme doesn’t profit us: The private sector

Sitting on a sprawling chair in a private hospital in the centre of Ilorin, a young medical officer, Sekina Jimoh wears a defiant countenance. Dressed in a floral chiffon blouse with a pen in her hands, Jimoh was drafting a prescription during this reporter’s visit.

According to her, the hospital has been running at a loss since the commencement of the scheme. She explained that:

“Challenges on our part are more of finances because of the capitation which is still not sufficient for the type of treatment we offer. There are a lot of old patients with hypertension and diabetes and other illnesses that patronize us every 10 days or two weeks and sometimes we have to run tests and dispense the required medications without charging them.”

Capitation is the payments agreed upon by a health insurance company and a medical service provider. They are fixed, pre-arranged monthly payments received by a physician, clinic, or hospital per patient enrolled in a health plan, or per capita.

According to the medical officer, the hospital ensures the capitation on every of their patient is judiciously expended and when it is exhausted, we ensure the treatment is completed or it gets to a safe stage before a referral, in case a need for that arises.

She explained that Kwara State wouldn’t reimburse for vital extra services rendered by the medical facility to members of the scheme. The capitation given is not enough, she stressed.

Asked how the hospital makes up for this loss, she said, “As per humanitarian service, well we can’t deny the patient his or her drugs. It will eventually be a burden on the hospital when the registered patient develops complications. So we attend to them and make up for it in other places when the possibility comes.”

She explained that primary and secondary treatments, primary and maternal care, child care, and malaria are the treatments her hospital offer. She, however, clarified that this is a general problem and that private hospitals are not discriminated against by the state government.

About the hospital’s referral policy under the scheme, she said: “We only refer patients when it is absolutely necessary. To do that, we reach out to the Kwara Health Insurance Agency with the patient’s details to release a code.”

“The “genuinely poor” are cheated out of the system”

Partnering with the Islamic Development Bank and a group of non-profit organizations dedicated to improving access to quality healthcare in Africa, PharmAccess, Kwara Health Insurance Scheme (KHIS) was designed to improve access to medical care by rural, and low-income communities who often struggle with high out-of-pocket expenses when seeking healthcare.

Touted as a unique initiative, government officials often claim this objective has not been derailed since the launch of the project. However, findings by Solacebase proved otherwise as high-income earners are gaming the system, thereby reducing the chances of poor people benefiting from the scheme.

The nurse and Officer-in-charge of Zango Ward Clinic and Maternity, Ilorin East Local Government Area (LGA) who simply identified herself as Khadijah recalls an incident when a wealthy car dealer came with his large family and several other employees to register as indigents.

“He would not agree to register otherwise and officials were left with no choice than to capture them as such,” she said.

Another nurse, Muslimah Adetoun lamented that wealthy indigenes come under the guise of not being able to afford the paid scheme. This invariably limits the chances of those who are genuinely poor.

She added that several registered members of the scheme have stopped patronizing hospitals due to  lack of confidence and poor access to the scheme adding that many people do not have official proof of enrollment. She lamented that many residents who enrolled have relocated from the communities where they initially registered and find it difficult to transfer their subscription to another clinic.

She explained that communicating with KHIS office is often challenging which makes giving them feedback discouraging.

“We tried to create a feedback channel so we can communicate some of the issues we encounter but that has been neglected as we are never able to reach them”

Kulende Primary Health Centre, Ilorin Eaast LGA, looks

deserted with old and rustic-looking equipment. Mariam Abdulkareem, a nurse, heads the PHC. Although she acknowledged that her PHC has 201 enrollees, a great number of people who require the service offered by the scheme are yet to benefit.

“There is a service offered by the scheme for civil servants but they haven’t added maternity fee for now. Up to 50 per cent of the capitation is given to the health centre and an extra is added during emergencies.”

“Some have registered and for long their names are yet to be officially captured and sent to the health centre. They have come up to complain several times about it, but I always tell them I’m not the one in charge so they always have to go home gloomy,” she lamented.

Primary Health Care is dead in Kwara, expert

Dr. Adekunle Salau is a medical professional who has been working in Kwara State for over ten years. He said the state is poor and struggles to pay the national minimum wage adding that poor remuneration eventually affects the health-seeking behaviour of the people.

“When the standard of living of a people is low, they won’t have a lot to spend on health and medical emergencies. Therefore, health insurance is supposed to step in to take care of that. Even the ones that are not emergencies, health insurance should be able to cover for it,” Salau said.

However, Salau opined that the availability of a health insurance scheme is not as important as the availability of quality health facilities to deliver the provisions of the scheme.

“If people are enrolled in the health insurance and are not able to access good healthcare, the purpose is defeated. They move away from PHCs to the general hospitals. The general hospitals are doing well but the issue is that they have a very high patient load and they are seriously understaffed. This, therefore, discourages a lot of people from visiting the general hospitals,” he added.

“But when the hospital close to you, can’t give you what you want then you would have no choice but to look elsewhere.”

He explained that it is difficult for people to fully benefit from the insurance scheme if there are no commensurate healthcare services, especially at the primary healthcare level which is usually the closest to them.

He stressed that PHCs are as good as dead in Kwara state. “Our PHCs are understaffed. It is one of the factors limiting people’s access to healthcare and rather fuels the bad habit of health seekers who rely on self-medication, patent medicine sellers and quacks.”

On efforts needed to create a linkage between health insurance and access to quality healthcare at PHC level, Salau said there is more work to be done as current realities don’t augur well for the country, predominantly the rural populace.

He explained that PHCs should be able to manage diseases such as malaria, and tuberculosis. But with the unavailability of drugs and necessary equipment, patients readily turn to alternative care.

“I understand it’s not the job of the insurance agencies to equip and staff health facilities but when these facilities don’t have the necessary working tools, the goal of the insurance scheme will be defeated. Equipping healthcare facilities should be where the real insurance should start from because that is where people who live in rural areas first turn to.”

The KHIS refused to comment on the issue. Initial multiple attempts to reach the executive director, KHIS, Dr Olubunmi Jetawo-Winter had proved abortive.

Later in a separate phone conversation with this reporter, Jetawo-Winter, promised to respond to the questions and asked that the email be resent.  When the questions were sent to her, Jetawo-Winter became evasive requesting the reporter to resend the email using an official email address. As of the time of filing this report, she still hasn’t replied the questions posed to her. Some of the questions contained in the email sent to her bothered on equitable utilization of the scheme, poor communication and feedback channel between the agency and other stakeholders amongst others.

Meanwhile, on May 27, the information desk of KHIS eventually replied to emails asking for comments. The desk promised to grant an interview with Solacebase on the issue soon.  As at the time of filing this report, the agency is yet to get back to this newspaper despite repeated reminders.

Efforts to reach out to the Country Directors of PharmAccess Foundation, Mrs Njide Ndili, and Regional Head, Islamic Development Bank, Mayaro were also unsuccessful. They are yet to respond to calls, emails and text messages sent to them at the time of filing this report.

This publication is produced with support from the Wole Soyinka Centre for Investigative Journalism (WSCIJ) under the Collaborative Media Engagement for Development, Inclusion and Accountability project (CMEDIA) funded by the MacArthur Foundation.