Olujobi: Many colours of a goldfish

By Editor on 20/09/2019

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Fayemi and Olujobi

The signs show quite early, many times. In the end, their imprimaturs dot the landscape as they etch their names across the pages of history. That is the way of men who achieve greatness, acquire greatness or have greatness conferred on them.

Part of the signs, is that distinct trait, which sets them apart from the rest. Somehow, it props up, sooner or later, but sure does. So, some carve their own niche right from the cradle, others at other times do along the finish-line. But no matter at what point they do, they usually conduce a huge influence and enduring impacts, for which society remembers them ages on. They are like a gold fish, whose many bright colours expose always.

The jury is out whether this garb fits Ayo Babatunde Olujobi just yet. But recent events, suggest that a sort of phenomenal characterisation is gradually building up. It is appearing on the horizon, in a unique but distinct manner like that of the ubiquitous image in the moon that gives vent to varied interpretations. 

Years of grit, toil, perseverance and complete adherence to the fine details of professionalism, appear to have offered him some strong planks, which when nailed together by times and circumstances, could form the platform for a leap into the exclusive arena of great men.

He seems to have finally waltzed himself into the podium where his years of robust advocacy on development of medical practice and other affairs of the society would be given a fresh impetus from the practical perspective. Opportunities, to transform views he had espoused, preached and adumbrated these years into demonstrable deliverables, are at his doorstep, it seems.

Of course, the derivable would have to depend on the interplay of other individual and divergent interdependent variables. But that tiny opening is all a genius requires. That tiny opening has opened in Ekiti State, his home.

Shortly after he was named into the board of Ekiti State Primary Health Delivery Agency (EKPHDA), he has also been called to serve in the Ekiti State Lawn Tennis Federation (ESLTF), two clear areas with the potentials of playing pivotal role in human development.

His inclusion into these key areas, underscores suggests that his success story in the critical areas of the health sector and his talents in sports, have not gone without notice and that his home government is bent on using them for greater purposes.

The trajectory of his medical practice, had, before now, made him a highly sought-after professional, for intervention into the critical area of primary healthcare, working on projects like the National Programme on Immunisation (NPI) and developing a template on National Health Insurance.

Some of his interventions, also included some literally work, on key areas of his specialisation. Some of these presentations, he made at different forums include: “Access and affordability of health insurance in Sub Sahara Africa,” “Inclusiveness of Health Insurance Scheme in Africa,” “Health Insurance Determinants in Nigeria” and “Willingness to Pay for Rural Health Insurance.”

As Medical Director of DONOLUSH HEALTHCARE SOLUTIONS LTD, he had also been visible in healthcare management, event and strategic healthcare solutions provision, and promotion of the business of healthcare in Africa.

One of the current activities of the company in this regard, is the coordination and management of outsourced Government owned Primary Health Centers (PHCs) in Lagos State facilitated by the World Bank Group and Pharmaccess with the objective to ensure availability of quality healthcare, accessible, their acceptability and ultimately affordability to all irrespective of their social status to achieve Universal Health Coverage (UHC).


This is apart from the general healthcare services the company focuses on, which includes healthcare management, project management, public health services, healthcare facility management, marketing and outsourcing, medical missions,  medical tourism, pharmaceuticals, medical and healthcare equipment supplies and solutions, Community Health Insurance Scheme, Hospice/Homecare Services, ambulance services and lots more.

Today, he has a new platform to drive the screw further, given the mandate handed down to him and his colleagues by Ekiti State Governor, Kayode Fayemi on April 11, 2019. The mandate enjoins the team to:

No doubt, his new brief has afforded him the opportunity to combine private practice with public policy and to drive his far-reaching postulations.

His roadmap to building a healthy populace which have drawn wide applause at various occasions, would now, assumedly, take a life of their own for the betterment of the society.  

Those with this expectation, have a surfeit of live examples to draw from on the basis of the dictum - “health is wealth.”

Today, for instance, Lionel Messi, football phenomenon, might have been confined somewhere in an awkward corner of the world space, if the Barcelona FC medical team had not resuscitated by dealing with his initial debilitating condition that would have ended his dream at the cradle and denied the world the pleasure of his iconic skills. Kanu Nwankwo, Nigeria’s own prodigy, would have had his own blossoming career cut short, were the Arsenal team not similarly taken care of his incapacitating heart conditions. These are just two samples from the reservoir that is replete in different fields all over the world.     

Such is the power of medicine that the duo has not only become big names in the sport, but multi-billion dollar money earners, wealth creators and institution builders, from which the world community now and generation to come will continue to benefit from.

The Kanu Heart Foundation (TKHF), has apart from giving life to countless children in Nigeria and saving families agonies of watching their wards perish, has the potentials of producing great Nigerians that could become icons in their own fields in future – men and women the world might actually be waiting for.

Just as good health is crucial and central to any form of human development, sports of any kind have also proved a potent weapon for striking down some of the life’s many vicissitudes. Delinquent youths, drug addicts and social misfits, have been straightened out. Many more have been pulled out of poverty and become world icons through sports. Imagine creating a Roger Federer or Serena Williams out of Ekiti State. Imagine the chain effect and the positive gains to the socio-economic development thereof.

No doubt, only very few people get the key to open future life’s opportunities, in the manner Olujobi has been called to do. No doubt, some even blow the opportunity by embarking on worthless fantasies.

Those who do find no place in history, especially the good side of it and many times become the butts of societal jokes by so doing. But, those who manage to rise above negative influences, end up building the bridge that connects the orchard of low-hanging fruits.

Perhaps, in years from now, many might be able to travel through the boulevard of history and find the name of Ogunjobi appearing boldly on its perspective. History beckons.


See some of the publications: 





MBBS(Ilorin), MPH(Lagos), Postgraduate Certificate Health Economics (Oxford), Postgraduate Certificate Monitoring & Evaluation (AMREF) 



10, Mabinuori Dawodu Street, Gbagada Phase 1, Lagos, Nigeria.

Email: donolush@yahoo.com 

www.donolushgroup.com Tel: 08084930338


An organized programme done in Gombe State, Nigeria. In attendant was the State Governor Ibrahim Hassan Dankwambo represented by the Deputy Governor. Others at the event were the stakeholders forum in Gombe State, the State Coordinator of NHIS, Gombe State Commissioner for Health, State Chairman of Nigeria Medical Association (NMA), State Coordinator of JOHESU, Traditional rulers, Religious leader, Market women Association and Civil Society Organisations.


Gombe State is located in the northeastern part of Nigeria, is one of the country's 36 states; its capital is Gombe. The boundaries of the state roughly correspond to those of the Tangale-Waja Chiefdom and Gombe Emirate, a traditional state. The state has an area of 20,265 km² and a population of around 2,365,000 people as of 2006. Gombe has 11 Local Government Areas and 14 Emirates /chiefdoms.






Quality of care is an important precondition for introducing health insurance, and health insurance is feasible when potential health insurance beneficiaries can access an acceptable quality of care. Also, the low quality of healthcare services in Nigeria presents a challenge for the introduction of a health insurance system and affects people’s willingness to participate in an insurance scheme or pay for services at any level.


Burden of inclusiveness of health insurance


Poor quality of services also affects health financing as a whole. For those services not available or of low quality, African citizens leave their continent, thereby spending those funds outside of their economy. For some procedures and surgeries, Africans like Nigerian people still go to other countries, like India, Germany, England and Turkey. Seeking care abroad due to poor quality of services often results in high levels of out-of-pocket (OOP) expenditure.


Although some countries had experience with health insurance for civil servants in the 1970s and community-based health insurance. Health insurance, which requires prepayment (premiums) to allow enrollees to receive health care at discounted costs or no costs when seeking care, is a new concept for most of the population. Many people think that paying money for insurance is worthless. The high level of illiteracy on healthcare financing and poverty rates pose further challenges to educating the population about health insurance. Even highly educated people who work in the formal sector, such as NGOs, would prefer to receive a medical allowance from their employer than to join health insurance programs.


Also, stakeholders had mixed opinions on the population’s willingness to pay. On the one hand, the demand for health insurance is increasing in the private market. Large organizations working in Nigeria and Africa continent are actively looking for suitable health insurance plans for their employees, largely because of the insecure working environment. In addition, health is often the second most important issue for the population, after food security. The high poverty rate and low awareness of health insurance limit the population’s willingness to pay. Additionally, the low quality of healthcare further reduces people’s willingness to pay for health insurance: quality again is an issue. Everyone would be willing to pay for quality services but [for] bad quality services, no one would be willing to pay; at least I’m not willing to pay.” Various stakeholders also expressed concerns for ensuring protection for the poor should new financing strategies be enacted.


Survey had shown that communities lack trust not only regarding insurance systems but also more generally in the government. There is reluctance from those stakeholders to contribute to public insurance scheme, because there is no equation of trust of government. This prevalent lack of trust extends to both the private and public sectors, and relates to the lack of security and volatile economic situation of the country. This general distrust creates an interesting phenomenon: the government feels the public does not trust private health insurance programs, and private companies feel the public does not trust government programs due to prevalent corruption and a sense that the government is unable to oversee a health insurance scheme effectively.


Introducing health insurance


After realizing challenges in many low- and mid-income countries to provide essential affordable quality care to populations, the World Health Organization (WHO) advocates the universal health coverage (UHC) agenda and further research on UHC [1]. One essence of UHC is to move away from direct payment to prepayment mechanisms as a means to improve access to care (both coverage of services and population) and to provide financial protection of the population seeking care. Given the high out-of-pocket (OOP) expenditure and limited access to quality care, Nigeria is in the early stage of UHC, and needs good and effective policy changes and reforms to accelerate the pace towards UHC. [1,2,3]


Experiences from other countries show that health financing reform and the introduction of health insurance are complex, long-term processes requiring strong technical and management capacity as well as political commitment from various stakeholders.[4,5,6] There is a growing recognition that health sector stakeholders have a strong influence on policy development and moving reforms forward in a country.[7] The inclusion of stakeholder perceptions, understanding, behaviors, interests, and intentions around health financing and health insurance will inform the feasibility of introducing health insurance schemes and the next steps to move forward. This is of particular importance in Nigeria and Africa continent, where the health sector is shaped largely by donors as funders, nongovernmental organizations (NGOs) as providers, and the government as the steward, regulator and provider.


Most people would agree with the idea that all individuals should have access to health services and should not face financial hardship if they fall ill or are injured.

More than 150 million people globally however, suffer financial catastrophe and 100 million fall into poverty due to out-of-pocket health expenditures every year.[9] The call for UHC - health systems providing both access to health services and financial protection -challenges the global donor community and governments to make efforts toward achieving this goal in the near future.


Nigeria is making efforts to achieve UHC. Nevertheless, a mere 3percent of the population is currently covered by the country’s national health insurance and government spending on health represents only 5.3 percent of GDP. Out-of-pocket payments for health equal over 95 percent of private spending on health and government spending only represents about 37 percent of total health spending. Weak governance and accountability, and inadequate health infrastructure render low levels of trust leading to unwillingness to invest health and minimal risk-pooling. Household poverty and inequality exacerbate this vicious cycle. An expansion of the National Health Insurance Scheme has been proposed through several pieces of legislation. The ability of the program to include large portions of the population beyond the formal sector seems a distant dream however. Alternatives must be considered to attempt to achieve UHC in the most populous country in Africa. Lessons learned from both large and small-scale interventions around the world, and in Nigeria itself, should be considered to begin to tackle this undeniably challenging task.



In countries, such as Nigeria, where the state is failing to provide its citizens with access to affordable quality health care, the solution to achieving UHC may be in risk sharing through


private community health plans and private delivery. A public-private partnership community- based health insurance (PPP-CBHI) model could be a stepping stone towards achieving universal health coverage, both in Nigeria and elsewhere. A successful such model is the Dutch Health Insurance Fund’s PPP-CBHI scheme in Kwara State, Nigeria. The program has begun to expand gradually and an evaluation of the scheme shows positive impacts on health care utilization, financial protection and health status. Unprecedented levels of investment in the health sector in this context over a short period of time attributable to the program are also a testament of its potential to contribute to the achievement of UHC.



The true success of the HIF model and the ability of the program to contribute to the goal of achieving UHC in Nigeria depend greatly on the sustainability of the program and the ability to scale it up. In Kwara, the program is developing into a State-wide insurance scheme in the next five years, covering up to 600,000 people in rural areas and the state government will increasingly contribute to the payment of the premium subsidy for low-income people and investing in healthcare infrastructure. Ownership, political will, local leadership, motivation and trust have been identified as key factors for the success of the program.

For a long time, donors and governments have opposed private sector involvement fueled by concerns over profit motives, issues with regulation, and fears of inequity. But increasingly it is recognized that, given the challenges faced in developing countries, health systems cannot do without the private sector. This shift is partly motivated by the expectation of decreasing aid budgets due to the global economic turmoil, but also by recognition of the dual realities of the weakness of public systems and the potentially significant contribution of private resources to health care delivery. The PPP-CBHI model utilizes and leverages the capacity of the private sector and aims to lower the threshold for investment in private health infrastructure.


It promotes the sharing of risk, stimulates additional private resources and avoids crowding out. This fosters innovation that can help reduce costs and improve efficiency. Donor funding is used to leverage private capital for the development of both supply (loans to and investments in health care providers and suppliers) of and demand (insurance) for quality health care. While it may seem a contradiction to suggest that a program like the HIF model that targets specific population groups could be the answer to achieving UHC in Nigeria, this strategy may effectively achieve the goal of 100 percent coverage. By focusing on rural populations, the poor or vulnerable, the unemployed, and the informal sector or those who typically are excluded from other forms of health coverage, UHC may in fact gradually be achieved in Nigeria one state at a time.




After the overview of some of the major impediments to the existence of health insurance, some of which are low quality of care, and low fiscal space, poverty, illiteracy, establishment of a health insurance scheme is not expected in the short term (one to two years). However, this circumstance suggests that the government and donors must work together to progressively prepare the country for introduction of quality and effective health insurance scheme. Nigeria and some African countries could learn from the experience of some low-income countries in


establishing health insurance, where both community-based health insurance and compulsory health insurance in the formal sector are implemented effectively.




  1. World Health Organization. The world health report: health system financing: the path to universal coverage. Geneva: Worlds Health Organization; 2010.
  2. World Health Organization. Health system financing: the path to universal coverage: plan of action. Geneva: World Health Organization; 2012.
  3. World Health Organization. The world health report 2013: research for universal health coverage. Geneva: World Health Organization; 2013.
  4. Mills A, Ally M, Goudge J, Gyapong J, Mtei G. Progress towards universal coverage: the health systems of Ghana, South Africa and Tanzania. Health Policy Plan. 2012;27 Suppl 1:i4–12.
  5. Atim C, Grey S, Apoya P, Anie S, Aikins M. A survey of health financing schemes in Ghana. Bethesda: Abt Associate; 2001.
    1. Purvis G, Alebachew A, Feleke W. Ethiopia health sector financing reform midterm

project evaluation. Washington: USAID; 2011.

  1. Brugha R, Varvasovszky Z. Stakeholder analysis: a review. Health Policy Plan. 2000;15(3):239–46.
    1. WHO. (2008a). World health statistics, 2008. Geneva: World Health Organization.






Dr. Babatunde Olujobi

MBBS(Ilorin), MPH(Lagos), Postgraduate Certificate Health Economics (Oxford), Postgraduate Certificate Monitoring & Evaluation (AMREF)


Donolush Healthcare Solutions Limited

10, Mabinuori Dawodu Street, Gbagada Phase 1, Lagos, Nigeria.

Email: donolush@yahoo.com 

www.donolushgroup.com Tel: 08084930338


Programme Host: University of Calabar Teaching Hospital.


Calabar is often described as the tourism capital of Nigeria. It is situated in Cross River State.Administratively, the city is divided into Calabar Municipal and Calabar South Local Government Areas. It has an area of 406 square kilometres (157 sq mi) and a population of 371,022 as at 2006 census.

In attendant: Representative of Commissioner for Health, Chairman of NHIS Cross River State, Chairman of NMA, Chief Medical Director of UCHT, Doctors, Nurses and other healthcare officers in Cross River State, the Traditional rulers.




Globally, it is noted that socio-economic status of individual plays a vital role in influencing their level of health care demand, health seeking behaviour, information about and/or utilization of health care facilities to aid their general health condition. This in particular is worrisome especially in sub-Saharan Africa like Nigeria where more than 70% of the population are of low social economic status, reside in rural community and are confined into the informal of the economy.


The decision to utilize health services involves several stages which include; visibility and recognition of symptoms, the extent to which the symptoms are perceived as dangerous, the amount of tolerance for the symptoms, and basic needs that lead to denial. Several factors including cultural, social, gender, economic and geographic are predisposing factors in the utilization of health services. The need for utilizing health services is borne out of the assumption that only special institutions charged with the responsibility of providing healthcare can provide relevant therapeutic services to people who have health problems.


The human capital is able to accomplish those desired objectives outlined by the society only on the fundamental premise that the people are in good health. Health is a basic fundamental right of all citizens and health promotion forms an intrinsic part of health care because a healthy society reflects the well-being of a nation.


The majority of the health systems in Sub-Saharan Africa are still heavily reliant on out-of- pocket (OOP) spending. The World Health Organisation reported that in 2007, private expenditure on health accounted for 58 percent of the total health expenditures compared to , 83 percent of the total private health expenditures, in this region are paid by households at the time of service (WHO, 2010).


From the foregoing, out-of-pocket (OOP) financing remains a dominant source of health financing in Sub- Sahara Africa, Nigeria included. Large out-of-pocket payments are both a burden and a barrier to accessing healthcare (Saksena et al., 2006). Out-of-pocket expenditures especially by poor households often lead to catastrophic expenditures and impoverishment. They also discourage use and reduce coverage of available health care services, both of which are important in improving health outcomes. (Mbugua et al., 1995;).

To enhance access to health care, health insurance is emerging as the most preferred form of health financing mechanism in countries like in Nigeria where private out-of-pocket expenditures on health care are significantly high and cost recovery strategies affect access to healthcare (WHO, 2000). It helps households to set aside financial resources to meet costs of medical care in the event of illness. Pabblo and Schieber (2006) note that health insurance improves risk pooling thus enhancing financial protection among households.


On the other hand, lack of health insurance promotes deferment in seeking care, non-compliance of the treatment regime and results in an overall poor health outcome (Hadley, 2002). The challenge facing developing countries therefore is to shift from OOP financing to pooling of risk arrangements and to ensure effective financial protection and coverage.


Different health financing policy initiatives have been undertaken in Kenya, all aimed largely at addressing affordability and access to health care services.




Myriad of factors has been associated with the demand for health insurance policy. This has been dictated by type of health insurance in question. Income has been cited as a key determinant by majority of the reviewed work (Kirigia et.al, 2005; Makika et.al, 2007; Hopkins and Kidd, 1992; Sanhuez and Ruiz-Tagle,2002)


Demographic factors such as age of the head of the household ,sex, living arrangements and marital status of the head of the household has been identified by many researcher as affecting the ownership of health insurance policy (Sanhuez and Ruiz-Tangle, 2002; Guis, 2010; Kirigia et.al ,2005; Takeuchi et.al, 1998). Apart from gender and age Torch and Claudia (2001) found expected expenditure in health through their prices and area of residence as key determinants of health insurance ownership. Area of residence was also found to determine ownership of health insurance by Guis (2010) though just like Owando (2006) and Torch and Claudian (2001) he found employment status of the household head to strongly affecting this demand.

Education level was also found to determine demand for health insurance ( Takeuchi et.al, 1998; Kirigia et.al, 2005; Bourne and Kerr-Campbell,2010; Makoka et al., 2007; Owando, 2006). Owando (2006) found that apart from education attainment level, self-evaluated health status supported demand for health insurance policy.

Risky behavior like smoking, alcohol use and non-use of contraceptives were found to accelerate demand for health insurance by Kirigia et.al.,(2005) and Owando (2006). This Risky behavior was associated with one expected health status. Health status was also found to be a significant determinant of ownership of health insurance policy by Hopkins and Kidd (1992), Sanhuez and Ruiz-Tagle (2002) and Cameron et.al., (1988).




It is believed that, lack of awareness on the various forms of health insurance could negatively affects the decision on health insurance coverage. Building awareness about health insurance coverage is vital. There is need to increase awareness levels on risk protection and risk reduction for risk takers (male and smokers) - media, ministry, scheme providers’ adverts and social marketing activities become helpful, as these help in the determinant of health insurance in Nigeria and Africa at large.


Also, other than concentrating on Social Health Insurance only, the government should also focus on developing other forms of health insurance. For instance, focus should be placed to


ensure more private sector participation in provision of health insurance. But this should also be coupled with more enhancing competitive behavior to encourage development of inventive and affordable insurance policy covers. Different policies and channels of promotion of insurance uptake are required for rural and urban areas.





Saksena, P., Xu, K. and Carrin, G. (2006). “The Impact of Universal Insurance on Catastrophic health Expenditure: Simulation Analysis for Kenya.” EIP/HSF Discussion Paper Series. Geneva. WHO. DP. No 8.

Mbugua, J., Bloom GH. and Segall MM. (1995). “Impact of User Charges on Vulnerable Groups: The Case of Kibwezi in Rural Kenya.” Social Science and Medicine. 41 (6): 829-835.

Pabblo, G. and Schieber, G. (2006). “Health Financing Revisited: A Practitioners’ Guide.” Washington DC, World Bank.

World Health Organisation. 2000. World Health Report 2000. Health System: Improving Performance. Washington D.C. World Bank

Hadley, J. (2002). “Sicker and Poorer: The Consequences of Being Uninsured”. The Henry J Kaiser Family Foundation.

Kirigia, j., Sambo,L., Nganda,B., Mwabu, G., Chatora,R. and Mwase ,T.,2005. “Determinants of Health Insurance Ownership Among South African Women”. BMC Health Services Research. 5(17): 1-10

Makoka, D., Kaluwa, B. and Kambewa, P. (2007). “Demand for Private Health Insurance Where Public Health Services are Free: The Case of Malawi.” Journal of Applied Sciences. 21:3268- 3273.

Hopkins, S. and Kidd, M. (1996). “The Determinants of the Demand for Private Health Insurance under Medicare.” Applied Economics. 28: 1623-1632.

Sanhueza, R. and Ruiz-Tagle, J. (2002). Choosing Health Insurance in a Dual Health Care System: The Chilean Case.” Journal of Applied Economics. 1:157-184.

Gius, M.( 2010). “An Analysis of Health Insurance Coverage of Young Adults.” Gius, International Journal of Applied Economics. 7(1): 1-7.

Takeuchi, D., Chung, R. and Shen, R. (1998). “Health Insurance Coverage among Chinese Americans in Los Angeles County.” American Journal of Public Health. 88: 451-453.


Torche, A.  and Sappeli, C. (2001). “The mandatory Health Insurance System in Chile: Explaining the Choice between Public and Private Insurance.” International Journal of Health Care Finance and Economics.1: 97-110

Owando, S. (2006). “Factors Influencing the Demand for Health Insurance in Kenya: A Case Study of Nairobi City.” MA Research Paper, Nairobi: Unpublished.

Bourne, P. and Kerr-Campbell, M.( 2010). “Determinants of Self-rated Private Health Insurance Coverage in Jamaica.” Health. 2(6):541-550.

Cameroon, A., Trivedi, P., and Piggott, J. (1988). “A Microeconomic Model of the Demand for Health Care and Health Insurance in Australia”. The Society for economic Analysis Limited. LV: 85-106






Dr. Babatunde Olujobi

MBBS(Ilorin), MPH(Lagos), Postgraduate Certificate Health Economics (Oxford), Postgraduate Certificate Monitoring & Evaluation (AMREF)


Donolush Healthcare Solutions Limited

10, Mabinuori Dawodu Street, Gbagada Phase 1, Lagos, Nigeria.

Email: donolush@yahoo.com www.donolushgroup.com Tel: 08084930338


A future health summit series in Lagos State.

Participants include; The representative of Lagos State Governor, Commissioner for Health, Lagos State Health Management board members, State coordinator of NHIS, Chairman of Nigeria Medial Association (Lagos Chapter), Opinion leaders, Royal fathers, Market men and women 




Universal healthcare coverage (UHC) has been difficult to achieve in many developing countries, 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 utilisation, 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) In this environment, community-based health insurance (CBHI) has emerged as an alternative to user fees. CBHI schemes are designed to ensure that sufficient resources are made available for members to access effective health care. (WHO, 2011) Contributions are accumulated and managed to spread the risk of payment for health care among all scheme members, although CBHI is known to be particularly vulnerable to adverse selection, where disproportionate enrolment by high risk contributors accompanies non-participation by low risk individuals.(WHO, 2011; Carrin, 2005)


There are various forms of CBHI, including mutual health organisations, medical aid societies and micro-insurance schemes. All are voluntary and apply the basic principle of risk sharing.(Carrin, 2005) Unfortunately, some CBHI schemes operating in sub-Saharan Africa (SSA), including that of Nigeria, have been hampered by low enrolment rates, limited resource mobilisation and poor sustainability.(De Allegri, 2009)

High levels of out-of-pocket spending and paucity of insurance mechanisms to pool and manage risk form a major challenge to health financing in Nigeria (Onwujekwe and Velenyi 2006). The Nigerian National Health Insurance Scheme (NHIS) currently covers only federal government public servants and does not provide cover for people employed in the informal sector. However, the government intends to expand the NHIS in the future so as to cover people employed in the informal sector, using community-based health insurance (CBHI) schemes. CBHI reduces out-of-pocket expenditure and improves cost recovery, and although its effects on the quality of health care and efficiency of health services are unclear (Ekman 2004), it appears to be the most appropriate insurance model for the informal sector and rural areas, where incomes are unstable.


The recommendation of the Commission on Macroeconomics and Health (WHO 2001) that out-of-pocket expenditures by poor communities should be channelled into community financing schemes may be a worthwhile venture in Nigeria. Nigeria’s use of out-of-pocket spending as the most important mechanism for health care payment is inefficient and inequitable (Soyibo 2004; McIntyre et al. 2005; Onwujekwe and Uzochukwu 2005; Ichoku and Fonta 2006; WHO 2007). Out-of-pocket spending is known to be a major hindrance to use of health care services (Palmer et al. 2004; Ichoku and Fonta 2006) and the burden is heavier on the poor and more vulnerable population groups. Households can fall into poverty due to catastrophic payments (Palmer et al. 2004; Poletti et al. 2007).


The introduction of CBHI in many parts of Nigeria, with its attendant benefits of protection from payment at the point of use of health services, is likely to be well received as it will be perceived as having the capacity to


improve access to good quality health care services. Segments of the population that have chronically depended on out-of-pocket spending for health care payment may be willing to pay for CBHI membership. This is because CBHI provides a way to avoid payment at the time of health service use (McIntyre et al. 2006), a major limitation of out-of-pocket spending. However, studies have shown that health insurance of any form is used by an insignificant proportion of people in Nigeria (Onwujekwe and Uzochukwu 2005; Onwujekwe and Velenyi 2006).


Previous studies found that most people were willing to pay for CBHI (Arhin 1995; Dong et al. 2003; 2005) but that the mean willingness- to-pay (WTP) amounts were low and depended on many factors such as socio- economic status (income), gender, education and place of residence. In particular, Dong et al. (2005) found that WTP for CBHI in Burkina Faso was dependent on the socio- economic status of respondents. They recommended that the premium for CBHI should be adjusted for income; otherwise a lower proportion of poor people will enrol.



CBHI schemes and their uptake in Nigeria


It is difficult to find up-to-date details of schemes currently running in Nigeria or recent national estimates of participation rates. Moreover, the NHIS was fully implemented only relatively recently (2005). Metiboba reported in 2011 a statement made in 2009 by Audu, the executive secretary for the NHIS, that only 3% of the entire Nigerian population was covered. Underlying problems have been reviewed more recently by Baba & Omotara (2013), who place the poor performance of Nigeria’s NHIS within the wider context of a fragmented approach to healthcare that involves both federal and state governments, a

deterioration in the public health service caused by a ‘brain drain’ and lack of resources, and the high levels of poverty encountered in Nigeria.


Examples of implementation of CBHI under Nigeria’s mixed informal sector model include the Hygeia Community Health Plan (HCHP), the first programme to be run in Lagos and Kwara State under the oversight of the Health Insurance Fund (HIF), an international not- for-profit organisation that undertakes to deliver private health insurance and services to low and middle income families. An ongoing study is assessing the ability of the HCHP to provide cardiovascular disease preventive care in a low resource setting. (Hendriks et al, 2011)


Other studies have focused on communities in Anambra     State,   where  a government/community healthcare co- financing scheme is in operation.( Adinma, 2010; This scheme mobilises the community via a health committee which has overseen refurbishment and re-equipping of the publicly owned health centre, sourced drugs and employed or re-deployed health personnel. The community members themselves set the premium to enrol at 100 and 50 Nigerian naira per month for each adult and child, respectively. The scheme focuses on maternal and child health. Enrolment in the scheme was reported to be 15.5% in a non-successful community but 48.4% in a successful one. (Onwujekwe, 2009) High enrolment was linked chiefly to increased awareness of the scheme, while low enrolment was linked to regressive contributions, failure to fit implementation to a specific area, insufficient community involvement, and lack of trust in the scheme and its management.(Onwujekwe, 2009)




Factors driving the success or failure of CBHI schemes appear as recurring themes in Nigeria and other SSA countries. Problems are chiefly operational in nature and include failure to account for the inability of the target population to pay for scheme membership, lack of clear legislative and regulatory frameworks coupled with inadequate financial support, and unrealistic enrolment requirements. The last is linked to failure on the part of administrators to align ‘real-world’ socioeconomic conditions, to account for the target population’s willingness to pay for a scheme, and to engage communities in decision making from the earliest stages. Failure to engage beneficiary participation in CBHI, lack of comprehensive cover and failure to appoint an omnibus regulator have all been criticised.( Metiboba, 2011) Moreover, patient preferences may not be receiving sufficient attention, and packages suitable for one community may not suit another.(Onwujekwe, 2010) These issues recur across countries that have faced significant difficulties in implementing CBHI. Problems with quality of service and a lack of trust in the integrity of the schemes and their administrators and providers have also been identified, particularly in Uganda, Guinea and Burkina Faso. Lack of awareness also continues to present barriers to enrolment (Onwujekwe, 2010): 97% of a sample of rural Nigerian surgical patients in one survey had no knowledge of their government’s insurance Schemes.(Dienye, 2011) Most had paid for their treatment from personal savings or had relied on family members. In Senegal, Moslems were found in the early 2000s to be much less likely than Christians to enrol because they mistakenly believed that the

schemes were open to Christians only.( Jütting, 2003)


Conversely, success factors are also evident. Researchers in Cameroon and Nigeria have documented a clear desire on the part of less well-off households to join schemes, and over 3000 Nigerian survey respondents stated that CBHI was an acceptable means of paying for health regardless of socioeconomic background or location.(Onwujekwe, 2011) Interestingly, the poorest households expressed the greatest willingness to enrol. Countries such as Ghana and Rwanda have shown key drivers of success to include uniform and comprehensive benefit packages, adequate finance by government and elimination or minimisation of copayments. Flat-rate payments are likely to discourage the very poor, and the use of funds from taxation has been shown to be necessary to avoid the need for regressive member contributions. (Onwujekwe, 2009) Even in a relatively successful country such as Senegal, there has been difficulty in reaching the very poorest members of society, which has highlighted the need for subsidies. (Jütting, 2003) Targeted subsidies for the most disadvantaged have a positive influence as long as adverse selection is avoided.(Adinma, 2010)


Providing a specific focus for CBHI (e.g. maternity services) has been shown to assist adequate funding and improve coverage in rural communities. (Adinma, 2010) Other initiatives of this kind include the Hygeia Community Health Plan (Lagos and Kwara State, Nigeria) that aims to improve access to cardiovascular care in low-resource settings. (Hendriks, 2011)


Conclusion /Recommendations Implementation of CBHI-type programmes within        the                   NHIS         of        Nigeria         has been disappointing                               to                     date,                            but                          experience elsewhere   suggests              that                  uptake             and sustainability could be improved through policies that include closer integration of the informal and formal sectors under the existing NHIS umbrella with increasing involvement of       beneficiaries    in                                 scheme                   design    and management,                 improvements                                         in communication and education, higher public and private healthcare funding, and targeted financial assistance. These findings are likely to be instructive for policymakers in SSA generally          in                     achieving                                 UHC          goals      and improving health outcomes.





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Access and Affordability of Health Insurance in

Sub Sahara Africa 


DR. BABATUNDE OLUJOBI MBBS(Ilorin), MPH(Lagos), Postgraduate Certificate Health Economics (Oxford), Postgraduate Certificate Monitoring & Evaluation (AMREF)



10, Mabinuori Dawodu Street, Gbagada Phase 1, Lagos, Nigeria.

Email: donolush@yahoo.com 

www.donolushgroup.com Tel: 08084930338


A health reform summit in Oyo State, Nigeria

Oyo State covers approximately an area of 28,454 square kilometers. The landscape consists of old hard rocks and dome shaped hills, which rise gently from about 500 meters in the southern part and reaching a height of about 1,219 metre above sea level in the northern part. Oyo State Health Insurance Agency has developed different healthcare plans to cover all categories of residents of the state in order to ensure that they have access to good healthcare services. These plans include; Standard plan, Top-up plans and students & Tertiary institution plan.


In attendant at the event: Oyo State commissioner of Health, State coordinator of NHIS, Traditional rulers, Religious leaders, Oyo State chapter of Nigeria Medical Association, Trade Union, etc.





Medicine benefits through health insurance programs have the potential to improve access to and promote more effective use of affordable, high quality medicines. Information is lacking about medicine benefits provided by health insurance programs in Sub-Saharan Africa.






Health insurance is intended to reduce the financial burden of purchasing health care by pooling funds and sharing the risk of unexpected health events. Risk sharing mechanisms are particularly important in Sub- Saharan Africa where most countries dedicate insufficient resources to health care and most health care, including medicines, is financed out-of-pocket.




In many sub-Saharan African countries, evidence shows that the poor bear the highest burden of diseases and experience high levels of catastrophic health expenditures.[1] Social health insurance (SHI) is considered a key mechanism for achieving universal healthcare by providing financial protection.[2] Social health insurance programmes are expected to protect people from catastrophic healthcare costs by pooling funds to allow cross- subsidization between the rich and poor and between the healthy and the sick. Some African countries, grappling with dissatisfaction from the public over exorbitant fees charged by health sector providers, have introduced social health insurance schemes as a way to ensure access to all income groups, especially the poor.[3] However, relatively little is known about the experience of how countries that have adopted this health financing strategy have tackled the issue of ensuring coverage of the poor.


Health insurance coverage can increase access to care and protect households from the detrimental economic effects of ill-health [3– 7]. Health insurance schemes often provide Review

coverage for inpatient care to mitigate sudden high financial burden due to hospitalization 8]. However, households in low and middle- income countries (LMIC) spend large proportions of out-of-pocket health care expenditures on medicines [3,5,9]. In 2002, house- holds in low income countries that earned less than US$1 per day devoted 53% of their health care expenditures to medicines

[10] and for almost half of poor house- holds, medicines accounted for all health care spending [5]. Extending health insurance coverage to outpatient medicines could reduce out-of-pocket medicines expenses, ensure greater access to essential medicines, and provide incentives for appropriate use [11].


To provide responsive and  affordable coverage for medicines, health insurance programs can employ a range of strategies to select and purchase products, design reimbursement policies, contract with providers, and manage utilization of medicines and other health care services [4,12]. Key tools include formularies with generics and cost-sharing policies; price negotiations with manufacturers; active purchasing of quality services from providers; and care management and improvement through targeted interventions and appropriate financial incentives [12]. One key to successful medicine benefit management is routine monitoring of medicines utilization and costs, using data that health insurance programs routinely have about their enrollees, health service providers, types of services used, and expenses incurred. Effective monitoring systems enable health insurance programs to track the impact of policies and programs to improve care and health among their members [4].


The World Health Organization (WHO), a global health body, reckons Africa bears a quarter of “the global burden of diseases but has access to only 3% of health workers and less than 1% of the world’s financial resources.” Barely a handful of African countries have met their pledge—made to the African Union—to pump at least 15% of their national budgets into health care.


In countries where one can get decent public health care, it comes at a price the majority can hardly afford. In some cases a two-tier system gives the rich access to quality care through private health insurance while the rest have to put up with overcrowded state-run facilities where they pay out of pocket.


Out-of-pocket payments


Regrettably, things are worsening. The World Bank reckons the share of out-of-pocket health payments as a portion of all health expenditures in sub-Saharan Africa rose from 40% in 2000 to over 60% in 2014. The effect of out-of-pocket payments can be catastrophic to families; it drags them into a poverty trap.


In the few African countries where national medical insurance schemes exist, they serve only a minority, according to WHO. In Ghana, WHO says, only a third of the population receives medical insurance under the country’s National Health Insurance Scheme. Nigeria’s national scheme covers less than 3% of its citizens. South Africa spends more on voluntary private health insurance as a share of total health expenditure (42%) than any other country in the world, says WHO. Yet  this scheme covers only 16% of the population. The country, which has unequal

access to health care among different socioeconomic groups, has started rolling out a single National Health Insurance System that will provide free health care to all South Africans. Rwanda is Africa’s trailblazer in providing universal health insurance. Its community-based national plan coverage rate is the highest on the continent. It covers 91% of the population. To reach this level, Rwanda trained thousands of community health workers—45,000. While health insurance is financed by both government and individual premiums, donors fund about half of Rwanda’s health budget. The most hard-up [Rwandans] pay nothing for membership in the programme, [while] wealthier folks pay about $8 a year, according to The Economist, a UK weekly. “Visits to doctors then cost just 30 cents. This is remarkable for a country whose national income, at $692, is one of the lowest in the world.


To reverse current trends, experts maintain that the private sector should take the lead in offering affordable prepaid insurance coverage, mostly to low-income families.


Embracing a new approach


In a New Paradigm for Increased Access to Healthcare in Africa, it has been argued that it is time to rethink the way health care is delivered in poor countries. It has been revealed that instead of focusing on governments as the major financers and providers of health care, the priority should be to encourage private-sector initiatives whose goal is “to provide affordable access to high quality health care for low-income households. Which outline a three-step strategy which is “essential to developing


viable health system that expand access in poor countries.


The first step is to target those who can pay and then align the demand and supply of health care through prepay arrangements, the same practice that has successfully transformed mobile phone companies in Africa. The second is to set up risk-pooling schemes from existing out-of-pocket payments that will lower costs, raise quality,

increase willingness to pay and boost contributed funds. The final step is to enforce quality standards in countries with weak regulations.


This would all sound theoretical as this model is not fully implemented in Kenya, Namibia, Nigeria, Tanzania and Uganda. The scheme is still in the early stages but rapidly gaining popularity with both health care beneficiaries and providers.





Conclusion / Recommendation

Africa’s health system is appalling. Only an overhaul could move it closer to United Nations Sustainable Development Goal Number 3 ensuring healthy lives and promoting well-being for all. Access to decent

health care is a daily struggle for the sick, due to seriously underfunded national health systems, lack of basic infrastructure to provide clean water and electricity and a serious shortage of health care workers.






1.World Health Organization. Health systems financing: the path to universal coverage. World Health Report 2010 Geneva :World Health Organization; 2010


2.  Mathauer I, Schmidt J-O, Wenyaa M. Extending social health insurance to the informal sector in Kenya. An assessment of factors affecting demand. Int J Health Plann Manage 2008;23(1):51- 68.


  1. Acharya A, Vellakka S, Taylor F et al. .Impact of national health insurance for the poor and the informal sector in low- and middle-income countries: a systematic review. London: EPPI- Centre, Social Science Research Unit, Institute of Education, University of London; 2012.


  1. Wagner A, Ross-Degnan D. Insurance systems in the Asia-Pacific region: improving appropriate use of and access to medicines. In: Eggleston K, editor. Prescribing cultures and pharmaceutical policy in the Asia-Pacific. Stanford, CA: Walter H. Shorenstein Asia-Pacific Research Center; 2009. p. 313–36.
  2. Wagner A, Graves A, Reiss S, LeCates R, Zhang F, Ross-Degnan D. Access to care and medicines, burden of health care expenditures, and risk protection: results from the world health survey. Health Policy; doi:10.1016/j.healthpol.2010.08.004.
    1. Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJ. House- hold catastrophic health expenditure: a multicountry analysis. The Lancet 2003;362(July (9378)):111–7.
    2. Xu K, Evans DB, Carrin G, Aguilar-Rivera AM, Musgrove P, Evans T. Protecting households from catastrophic health spending. Health Affairs 2007;26(July (4)):972–83.
    3. Jütting JP. Do community-based health insurance schemes improve poor people’s access to health care? Evidence from rural Senegal. World Development 2004;32(February (2)):273–88.
    4. World Health Organisation. World health survey; 2003. http://www. who.int/healthinfo/survey/en/index.html [accessed 10.01.10].
    5. Vialle-Valentin CE, Ross-Degnan D, Ntaganira J, Wagner AK. Medicines coverage and community-based health insurance in low- income countries. Health Research Policy and Systems 2008;6:11.

11.  Second international conference on improving use of medicines. Policies and programmes to improve the use of medicines: recom- mendations from ICIUM 2004. 2004. http://www.icium.org/      icium2004/Documents/ICIUM2004PolicyAndProgramme Recommendations.doc [accessed 02.02.09].


  1. Faden L, Vialle-Valentin C, Ross-Degnan D, Wagner A. The role of health insurance in the cost-effective use of medicines in low- and middle-income countries. Health Policy; this issue.


Source Whirlwindnews.com

Posted on September, 20 2019

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