Pillar 1: Health Infrastructure Within Neighbourhoods

Pillar 2: Modules of Community Health Personnel

Pillar 3:  Membership Fee As Health Financing:        

Pillar 4: Community People Involvement

Pillar 1: Primary Healthcare Infrastructure:

These are Open Access, Walk-In Clinics in peoples' neighbourhood across the state. The Clinics will be equipped with essential medicines and essential diagnostic point of treatment kits. The Clinics will publish daily doctors' visiting hours. The Clinics will operate with a protocol of referral to secondary care.

Pillar 2: Modules of hierarchical community health personnel

A Module of personnel consists of 16 Key Workers recruited and trained to resspond to contacts from the people about their health needs. The 16 Community Key Workers will be Task Sharing and Task Shifting with 4 qualified nurses using approved Clinical protocols supervised by a registered medical practitioner. The referral protocol uniquely includes private health institutions in the referral system.

Pillar 3: Health Financing and Health Insurance

Residents of the local neighbourhoods will have open access to the Walk-In Clinics. They will be enrolled as members of Mutual Health Associations. The membership fees of the MHA will be used as insurance premium for members. 

Pillar 4: People Involvement

Local people will be recruited into Mutual Health Association Committees to manage the Walk-In Clinics by organising membership of the MUTUAL HEALTH ASSOCIATION, MHA. The committees will carry out membership drives. Membership of the MHA will be free for one month when initial free health check up will be carried out. Thereafter, membership fees will be payable and this will be used as insurance premium for primary healthcare and ambulatory health services for members. This requires a critical number of people to be enrolled into the MHA.

These 4 pillars combine Community Governed Primary Healthcare and Community Governed Health Insurance into an innovative Hybrid Model to deliver Universal Health Coverage in Ekiti State, Nigeria

1. Background and Rationale

Nigeria has committed to Universal Health Coverage (UHC), yet insurance enrollment remains limited and out-of-pocket health expenditure remains high. Primary healthcare delivery is fragmented, and communities are often treated as service recipients rather than structural participants in financing and governance.

Healthcare Access Covenant Foundation (HAC) was established to translate UHC from policy aspiration into community-level implementation in which the people are at the core of management health insurance enrollment and governance of the system.

Our model aligns with the mandate of the National Health Insurance Authority of the federal government of Nigeria and global UHC principles advanced by the World Health Organization that primary health care is better achieved with involvement of the local people.

By its characteristics, Ekiti State provides a viable reform environment for piloting a scalable,  cooperative-based primary healthcare system that integrates pre-paid financing of membership fees as insurance premium for primary health care services and accountable community governance.

2. Problem Statement

In Ekiti State, like the rest of Nigeria, the key challenges include:

* Low enrollment in structured health insurance mechanisms

* High out-of-pocket primary care expenditure

* Limited integration of private providers into insurance networks

* Weak community participation in health financing governance

* Vulnerable populations excluded from prepaid systems

Without structured enrollment and local ownership, progress toward UHC remains virtually impossible.

3. Project Goal

To establish a cooperative-based, community-governed primary healthcare network of clinics in Ekiti State, called Mutual Health Association Clinics. These integrate insurance financing, structured service delivery, and measurable accountability systems using the 4-Pillar approach.

4. Project Objectives (36 Months)

4.1 To establish 3–5 Community Mutual Health Association (MHA) Clinics in selected Ekiti communities, in the first year and 22 Clinics in the second year.

4.2 To Enroll 5000-8000 individuals per clinic into structured primary healthcare delivery paid for by membership fees of the MHA as insurance premium.

4.3 To Provide targeted contribution subsidies to 23,000–50,000 vulnerable individuals within our enrolled population, identified through a validated means-testing protocol.

4.4 Demonstrate measurable improvement in financial protection and primary care utilization.

4.5 To demonstrate sustainability of our health service-health insurance hybrid approach,

4.6 To publish outcomes demonstrating a scalable implementation framework for expansion within Southwestern Nigeria.

5. Intervention Model

Community Mutual Health Associations (MHAs) Clinics 

Neighborhood-based clinics owned and governed cooperatively by members of the community.

Services include:

Preventive annual health assessments for all members 

Free primary care consultations for all members 

Essential medicines within approved protocols

Coordinated referrals for secondary health care, both public and private 

Community-based follow-up after hospital discharge

6. Membership Structure

Open Membership:
Open Membership will be made available for all residents of the community to enjoy free initial access to services

Insured Membership:

Open Members who their membership fees will become Insured Members. The Annual prepaid membership fees is NGN 22,500 (in 2026).

Subsidy Framework

A community-validated, means-tested vulnerability assessment tool will be used to identify individuals who are VULNERABLE and eligible for sponsored membership contributions. Inter-rater reliability and transparency safeguards will be built into the protocol to avoid acrimony.

7. Financing Strategy

Apart from the membership fees of the MHA, the model explores other sources of revenue, namely:

Capitation payments via NHIA-aligned insurance mechanisms

Institutional grants

Targeted subsidies for vulnerable households

The objective is gradual transition toward operational sustainability by Year 3.

8. Expected Outcomes

By the end of Year 3:

*100% awareness of the benefits of pre-paid fees, health insurance, to gain quality health care.

*Increased insurance participation within target communities

*More than 10% of the population of Ekiti of 3.5 million people are enrolled in structured primary healthcare through membership of neighourhood MHAs

*Reduced risk of catastrophic out-of-pocket primary care expenditure

*Improved utilization of preventive and ambulatory services

*Community-elected governance structures actively overseeing clinical and ethical performance of primary health services.

*Contributing to Sustainable Development Goal 3 of the United Nations.

9. Monitoring & Evaluation

HAC will implement a structured Monitoring and Evaluation framework tracking:

Enrollment and retention rates of each Mutual Health Association 

Service utilization indicators of the people, including the vulnerable people 

Financial performance metrics

Member satisfaction

Comparative analysis with non-participating communities (where feasible)

Independent financial review and periodic impact reporting will be conducted.

10. Governance & Institutional Capacity

HAC operates under:

A Board of Trustees

Clinical Audit Committee

Community-elected members of Mutual Health Associations committees

Independent financial oversight mechanisms

Regular audit of Conflict-of-interest and financial disclosure policies in place

11. Funding Request

HAC seeks an investment of USD 1.2 – 1.8 million over 36 months to support:

Establishment of 40-45 Mutual Health Association neighbourhood clinics

Training and deployment of 50 Modules of health personnel

Digital enrollment and health records systems

Initial staffing and operational support

Vulnerable household subsidy pool

Monitoring, evaluation, and independent assessment

Detailed budget breakdown and implementation timeline are available upon request.

12. Conclusion

Healthcare Access Covenant Foundation is building a structured, cooperative, community-owned primary healthcare model designed to advance Universal Health Coverage sustainably and at scale. This is not a health mission but a health system designed to be sustained by people involvement. It is health of the people, by the people, for the people.

This initiative represents an opportunity to move from policy commitment to measurable implementation within a replicable Nigerian context.