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| REVIEW ARTICLE |
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| Year : 2022 | Volume
: 27
| Issue : 4 | Page : 319-325 |
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Improving access to diabetes care in Nigeria – The GIFSHIP opening
Chidimma B Nwatu
Department of Medicine, Faculty of Medical Sciences, College of Medicine, University of Nigeria, Ituku/Ozalla Campus Enugu, Nigeria
| Date of Submission | 30-Jan-2022 |
| Date of Decision | 07-Apr-2022 |
| Date of Acceptance | 14-May-2022 |
| Date of Web Publication | 22-Sep-2022 |
Correspondence Address:
Chidimma B Nwatu
Department of Medicine, Faculty of Medical Sciences, College of Medicine, University of Nigeria, Ituku/Ozalla Campus Enugu
Nigeria
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijmh.ijmh_33_22
Diabetes mellitus, has continued on a relentless upward trajectory globally, with profound socio-economic consequences. Not surprisingly, the International Diabetes Federation in collaboration with the World Health Organization and the United Nations; in commemoration of the World Diabetes Day 2021, aptly chose the theme – ‘Access to Diabetes Care - If Not Now, When?’ for the year 2021 (the centenary anniversary of insulin discovery), till 2023; to underscore the difference which having access to diabetes care can make, in relation to diabetes management. The Group, Individual and Family Social Health Insurance Program (GIFSHIP) is a non-formal sector insurance package for individuals; groups; and family units in Nigeria, recently introduced by the federal government, to improve universal health coverage.
The inherent positive contributions of the GIFSHIP, towards improving access to diabetes care in Nigeria was reviewed.
MEDLINE, Omni and Google Scholar searches were conducted using keywords - access to diabetes care, barriers to diabetes care, GIFSHIP, and Nigeria. Relevant studies were extracted and reviewed. Authors summarized health care access, narrowing down to diabetes care access. The opportunity for improved access to diabetes care, which the GIFSHIP presents was highlighted. The role of the Diabetes Association of Nigeria (DAN) in advancing the uptake of, and utilization of the GIFSHIP package for their members, was explored.
The GIFSHIP showed great promise for improving access to diabetes care in Nigeria, while the DAN was projected as an effective channel for dissemination and uptake of the GIFSHIP among individuals with diabetes. Keywords: Access to diabetes care, barriers to diabetes care, GIFSHIP, health systems, Nigeria
How to cite this article:
Nwatu CB. Improving access to diabetes care in Nigeria – The GIFSHIP opening. Int J Med Health Dev 2022;27:319-25 |
| Introduction | |  |
Access to health care for all, devoid of financial hardship, is the primary aim of the universal health coverage (UHC) agenda,[1] and achieving this goal of UHC, was one of the prime targets when countries the world over, adopted the Sustainable Development Goals (SDGs) in 2015.[2]
Having access to health care and particularly, to diabetes care is important as diabetes remains one of the most distressing contemporary diseases especially in resource-constrained countries like Nigeria.[3] Additionally, the presence of diabetes complications and associated co-morbidities significantly impair the quality of life of individuals with the disorder,[4] mostly due to lack of access to diabetes care.
Sadly, three-quarters of the 537 million adults with diabetes the world over, reside in low-and middle-income countries, while Africa has been projected as the region to experience the steepest ascent (by 129%) in the total number of people living with diabetes come 2045.[5]
In Nigeria, of the more than 3.6 million people with diabetes, close to half (46.4%) are undiagnosed,[5] placing them at high risk of developing multiple diabetes complications. Therefore, improved access to diabetes care is imperative, to reverse the daunting epidemiological data from Nigeria.
Access to health care generally, with emphasis on access to diabetes care and suggestions on novel strategies to improve access to diabetes care in Nigeria will be discussed.
| Health Care Access | | |
This entails having the opportunity to utilize needed quality health care services in a timely manner[6] and comprises at least four components which must be present to ensure that disparities in health care access are greatly minimized.[7] These components include – 1) Coverage: entails having health insurance, which facilitates the individual’s formal entry into the health care system, as studies have shown that individuals who are uninsured are less likely to receive health care.[7] 2) Services: Individuals with a regular source of care and an accustomed health care provider have better health outcomes, lower costs and a higher chance of receiving recommended screenings and preventive services.[7],[8] 3) Timeliness: represents the health system’s innate capacity to offer care as quickly as possible, once a need arises.[7] 4) Capacity of the workforce: entails having well-qualified health care providers and adequate health system infrastructure, both of which ensure a well-coordinated health care delivery.[7],[9]
Access to health care therefore is multi-faceted, with independent but complementary constituent parts, all of which must be present to bring about optimal health care delivery.[10],[11]
Disturbingly, disparities in access to care still exist, especially among vulnerable groups, typically involving individuals from poor households, noted to have worse access to health care services on every access indicator measured.[12] Likewise, certain gender-based cultural practices were noted to be associated with disparities in health care access and poorer health outcomes in the under-five group.[13]
Nigeria’s health system ranks abysmally low, due to its sub-par performance regarding healthcare access and quality.[14] Lack of workforce capacity is also evident, especially in northern parts of the country.[15] Poverty remains one of the greatest impediments to accessing health care, even when such individuals live very close to a health facility.[16],[17],[18]
Other groups with disparities in access include older adults, individuals with disabilities or co-morbidities, rural residents and individuals with special health needs.[19],[20]
| Access to Diabetes Care in Nigeria | | |
Nigeria is a low-middle-income country[21] of over 200 million people,[22] with multiple ethnicity[23] and fast-changing population dynamics.[24] Daily, hundreds and thousands of the populace troop into already overcrowded, poorly planned cities from the rural areas, in search of jobs. Giving rise to rapidly expanding inner city slums. Above scenario expectedly, leads to declining health indices consequent upon sedentary living and changing dietary habits tending towards highly processed, high-saturated fat, energy-laden instant meals, bereft of essential micronutrients. This highly ‘atherogenic diet’ – a notorious augury of endothelial dysfunction – predictably, over time, results in more extensive atherosclerotic vascular disease[25] typically manifesting as coronary and peripheral artery diseases.[25]
A recent meta-analysis of diabetes prevalence studies in Nigeria revealed a pooled diabetes prevalence of 5.77% with wide inter-regional variations in the pooled prevalence figures.[26] However, close to half of those with diabetes are not aware of their status,[5] and many end up presenting to health facilities, for the first time, with diabetes complications.
Access to diabetes care in Nigeria is grossly inadequate due to severe shortage of both health care facilities and health care personnel, as authors have reported a shocking doctor-to-patient ratio of 1: 208,978 and a midwife-patient-ratio of 1: 104,489 in a certain local government area, North-West Nigeria.[15] With less than a quarter of the 30,000 primary health care centers in Nigeria being functional, primary levels of care are at worst non-existent in locations where they should exist, and at best severely under-staffed and under-equipped.[27] Thus, this vital first level of care where majority of the population with diabetes should present first, when in need of health care services, is virtually non-existent. Hence, majority of Nigerians with diabetes present late to the few, barely-functioning secondary health facilities, while a good number of patients with advanced complications how up for the first time, to the sparse tertiary level health facilities available nationwide.[28]
| Domains of Access to Diabetes Care | | |
Access to diabetes care may be discussed under these four constituent health care access categories: Insurance coverage; Health care services; Timeliness of care and Workforce capacity.[7]
Insurance Coverage –
Affords the individual with diabetes a formal opening for entrance into the health care system and is the corner stone upon which other domains of access are built. A key goal of the UHC is the minimization of out-of-pocket (OOP) payments at the point of health care delivery for individuals. In Nigeria, the National Health Insurance Scheme (NHIS) was introduced by the central government in 2005 to guarantee easy access to health care for her people.[29],[30] The initial structure was such that only individuals employed by the federal government or the organized private sector (both constituting the formal sector), could be enrolled. The scheme later on expanded in scope, to involve a small segment of the informal sector, through various sub-schemes, however, these failed to achieve added coverage for the intended population as conceptualized. Although the NHIS has made significant strides towards achievement of UHC in the formal sector,[31] its total population impact, sadly, is still abysmal at <5% coverage.[30],[32] Thankfully, a recent policy change favors an extension of benefit for formal sector retirees by a few more years, post-retirement.[33] Diabetes mellitus being a chronic disease with exacting complications, can affect people of all ages; with type 1 diabetes (T1DM) affecting predominantly the very young. The NHIS as structured initially, leaves out coverage for a large proportion of this vulnerable group who require obligatorily, daily and expensive insulin injections, plus other treatment modalities for continued survival. Additionally, the most predominant form of diabetes – the type 2 diabetes (T2DM) is associated with advancing age[34] and hence may just be developing in an individual as they are exiting from formal employment (around the age of 60 years), again leaving them out of insurance coverage. Although various state governments in Nigeria have commenced a state-based social health insurance program (SSHIP),[35] majority of individuals living with diabetes, still remain without health insurance coverage. Therefore, many continue to pay OOP, for needed health care services and life-saving medications.[36]
Access to Diabetes Care –
This is very important for people living with diabetes because of their highly individualized care. Additionally, as people living with diabetes increasingly get actively involved in the management of their condition, it becomes necessary that they have both a regular place of care and a trusted care provider who will help them navigate the convoluted terrain of diabetes self-management and care.
Timeliness of Diabetes Care –
this measure of access to care appraises the likelihood that an individual who needed immediate care for an illness or a medical condition, actually got the required care as soon as wanted.[7] Its absence has consistently been associated with increased morbidity and mortality especially for chronic diseases such as diabetes.[28],[37] In Nigeria, where >90% of the population, including individuals with diabetes engage in OOP at the point of health care service delivery,[38] achieving timeliness of care is vital, as patients present to a health care facility only when they have money available to pay for the services. The obvious implication of this is that many people living with diabetes delay assessing needed diabetes care for many weeks, for lack of funds. This, expectedly, is a major driving force for the development of diabetes complications. Therefore, the need for health insurance coverage for individuals with diabetes cannot be over-stated.
Health Care Workforce Capacity –
the availability of adequate, well qualified health care practitioners, distributed equitably in urban and rural areas is a key ingredient of a resilient health system infrastructure.[39] This is especially important as regards patients’ access to diabetes care in Nigeria, as there are at present, grossly insufficient number of doctors for the teeming Nigerian population. In addition, Endocrinologists and Diabetologists who are physician experts in diabetes care are less than 200 in Nigeria, as at a decade ago[40] (though more current figures may not be significantly different owing to the recent brain drain among specialist physicians), with a few dozens more currently in-training, concentrated mostly in the few tertiary hospitals located in urban cities.
| The Gifship Opening for Improving Access to Diabetes Care | | |
In view of the lack of effective social health security coverage for people outside the formal sector in Nigeria, there arose an urgent need to fill this gap in order to achieve the mandate of the NHIS which is UHC for all Nigerians. This then led to the design and development of – the Group, Individual and Family Social Health Insurance Program (GIFSHIP), which was formally flagged off on 26th November 2020,[41] and subsequently launched in three pioneer states of Anambra, Osun and Oyo respectively in 2021.[42] The GIFSHIP is a novel and innovative social health insurance scheme designed to expand coverage opportunity for Nigerians outside the formal sector of both the federal and state governments. It was designed specifically to capture all other categories of people, who were not previously covered under any sub-arm of the National health insurance program, thereby providing them much-needed financial access to health care. This includes children, the youth, the self-employed, artisans, small business owners and their staff, individual family members and non-cohesive groups such as associations and unions outside the organized private sector.[43] Others include - diaspora groups, foreigners living in Nigeria, retired federal and state government workers and other special groups[43] such as – adopted group of persons paid for, either by Philanthropists, or as part of constituency projects sponsored by members of the National Assembly.[44]
| Financing for the Gifship | | |
The scheme is funded from contributions made by interested persons with rates as detailed:
Individual Subscriber –
An individual subscriber contributes N45,000 ($108) per annum which also enables him to add two direct dependents, thereby averaging a coverage cost of N15,000 ($36) per person.[43]
Family Unit –
A family unit will contribute N60,000 ($144) for four biologically related persons. An additional dependent of a given family will be enrolled at N15,000 ($36).[43]
Group Enrollment –
The minimum number for a group shall be ten persons, with the exception of small scale enterprises with less than ten employees. Contribution rate for group enrollment is N15,000 ($36) per person, per annum and the above-stated rates are subject to changes from time to time as may be determined by the NHIS.[43]
| Benefit Package Under the Gifship | | |
Enrollees under this scheme are entitled to the following:
Primary Level Health Care Services which include: out-patient care; health education, counselling and management of Internal Medicine, simple Surgical, Pediatrics, Obstetrics and Gynecological services. Others include Mental Health services, HIV and AIDS care, Ophthalmology services, Ear Nose and Throat care; Dental care; Ante-natal, delivery and post-natal services with select investigations; Family Planning services; Physiotherapy and Emergency care services; excluding those that cannot be handled at the primary care level.[43]
Simple laboratory investigations; immunization services and simple surgical procedures are also undertaken.[43]
Secondary Level Health Care Services –
all other management procedures and emergency care that cannot be effectively managed at primary care level must be referred promptly, to a secondary care center, as appropriate. Some services offered at the secondary level include: more advanced medical; surgical and other specialized procedures including emergency conditions that cannot be effectively managed at the primary level of care.[43] Included here also are all cases of multiple gestation, Caesarean sections, all first pregnancies and grand multiparity as well as all preterm babies for a period of 12 weeks from delivery date.[43] All Radiologic and Ultra-sonographic investigations, except those on the exclusion list of the NHIS are also included here.[43]
Tertiary Level Health Care Services –
All Medical, Surgical, Pediatric and other specialist care services that cannot be managed effectively at the secondary care level must be referred promptly for tertiary level care, except those on the NHIS exclusion list.[43],[45]
| Exclusions for the NHIS | | |
Some conditions and procedures are excluded from the benefit package of the NHIS and include:
Industrial/Occupational injuries (covered under the Workmen Compensation Act); Injuries from natural disasters; Cancer treatment other than cervical and breast cancer; amongst others.[45]
Items on partial exclusion include – high technology investigations such as Computerized Tomography scan; Magnetic Resonance Imaging and dialysis for acute renal failure (maximum of 6 sessions).[43]
Further details on the GIFSHIP enrolment, commencement of access, renewal of enrolment as well as financing for items on partial exclusion list are as described in the NHIS-GIFSHIP document.[43]
| The Role of Dan in Advancing the Gifship Scheme for Individuals With Diabetes in Nigeria | | |
The Diabetes Association of Nigeria (DAN) is a diabetes support group,[46] affiliated to the International Diabetes Federation (IDF)[47] The DAN focuses primarily on health promotion and socio-economic advancement of Nigerians living with diabetes. It also functions to disseminate vital knowledge and practices regarding diabetes self-management, as the association currently has chapters in all the 36 States of Nigeria, including the Federal Capital Territory.[46] Additionally, the DAN also contributes towards the improvement of diabetes care in Nigeria, by forging a strong health initiative through diabetes advocacy at various levels; development of educational materials to aid better understanding of the disorder; regular population enlightenment regarding diabetes preventive measures and early symptoms.[46],[48] Since the DAN is a well-structured diabetes advocacy group with a nation-wide reach, it could and indeed should be utilized, for the sensitization and advancement of uptake of the huge benefits inherent in the GIFSHIP scheme, among individuals living with diabetes in Nigeria.
Additionally, state Chapters of DAN may act as informal fund collection outlets whereby, members with financial constraint, may contribute their yearly GIFSHIP financial subscription in smaller/affordable amounts, for instance, monthly or quarterly.
Better still, the leadership of DAN may collaborate with major relevant state actors, to push for group sponsorship for their members, by willing legislators, under the constituency projects scheme of the National Assembly,[49] as earlier recommended by some members of the House of Representatives in Nigeria.[44] Indeed, the Nigerian Bar Association has taken the lead in group enrollment recently, by formalizing an agreement with the management of the NHIS to enroll 1000 lawyers, at the first instance, on the GIFSHIP platform.[50]
| Summary and Conclusion | | |
Impediments to diabetes care still exist, even in high-income countries, and impact negatively on patient’s ability to get high quality, needed care promptly.[51],[52] Indigence ranked highest among barriers to diabetes care, while shortage of specialist care providers and dysfunctional primary health care system were also identified as significant barriers to diabetes care in Nigeria.[18] Above findings further buttresses the point that OOP spending by patients at the point of health care delivery should be curtailed. Indeed, in a commentary on the 100th year anniversary of insulin discovery (year 2021), Peters was unequivocal in stating that the biggest barrier to diabetes management was access to care, with high cost of insulin, (a life-saving drug for diabetes management) at the heart of the problem[53] a fact corroborated by Oluwayemi et al. in their study on childhood diabetes in Nigeria.[54] Additionally, about 30 million people worldwide, who require insulin could not afford it due to its high cost,[53],[55] and not surprisingly, majority of these individuals reside in middle and low-income countries such as Nigeria. Besides financial constraints, low levels of awareness for diabetes; poor knowledge of diabetes self-management education; General Practitioners’ sub-optimal knowledge on diabetes management and difficulty in accessing a health facility for needed diabetes care were also identified as additional barriers to diabetes care in Nigeria.[18],[56]
Thankfully, the World Health Organization (WHO) has recently included long-acting insulin analogues (insulin degludec; determir and glargine) and new oral medications for treatment of diabetes, on its list of essential drugs, all in a bid to prioritize access to diabetes care.[57],[58] Other multi-nationals have also partnered with state governments in Nigeria, towards improving access to diabetes care.[59]
In view of this therefore, fund pooling and financial risk sharing through a health insurance scheme must be adopted mandatorily in Nigeria, to ensure improved access to diabetes care.[60]
The DAN, being a well-structured diabetes advocacy group, should be leveraged for the effective uptake of the GIFSHIP among its members, to radically improve access to diabetes care in Nigeria.
Financial support and sponsorship
Self-funded.
Conflicts of interest
There are no conflicts of interest.
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