Achieving Mandatory Health Insurance Coverage

While Nigeria’s National Health Insurance Scheme has been made optional for its citizens, a reason experts say has stunted the scheme, the progress made so far by Delta State, the first to implement the mandatory health insurance programme in the country, has shown that universal health coverage is achievable. Martins Ifijeh writes

Nigeria introduced the National Health Insurance Scheme (NHIS) in 2005, the same year Ghana launched its own. However, while the Ghana scheme has covered well over 50 per cent of its population, the Nigeria NHIS seems stuck at coverage of about four per cent of the population, leaving a major chunk of the citizens, especially the poor, to pay for healthcare from their pockets; an approach that has not only made them poorer but has increased mortality rate.

No wonder statistics have shown that 12 years after the establishment of the scheme, the level of out of pocket expenditure as a share of total health expenditure is still placed at 72 per cent, the highest on the continent and one of the highest in the world. Even poorer countries in sub-Sahara Africa like Kenya (26 per cent), Gabon (22 per cent), among others are doing better.

Information also show that countries afflicted with conflict and post-conflict like South Sudan (54 per cent) and Sierra Leone (61 per cent) are still better than Nigeria , leaving stakeholders in the healthcare industry to ponder on the model used by the government to run the scheme.

The slow growth of the scheme however prompted the Health in Africa Initiative of the International Finance Corporation of the World Bank Group to conduct a study on the Nigeria NHIS where it identified some constraints affecting the expansion of the coverage.

Issues identified include the voluntary nature of participation of the scheme, the lack of buy-in by state governments, the lack of a robust ICT platform to implement the scheme, and the lack of clarity on the regulatory functions of NHIS, for instance, its implementation of a public sponsored scheme.

Following the acceptance of the report by the management of the NHIS in 2013 the agency proceeded to implement some of the recommendations which included the recognition of state governments to set up their State Supported Health Insurance Schemes (SSHIS) through a National Council of Health memo approved in March 2014 by the federal government.

The memo, which contained features of what a typical SSHIS should look like, listed the legal basis of the SSHIS approved by the State House of Assembly and signed by the Governor of the state. It also highlighted how states should increase the share of total health spending by committing compulsory sources of funding to health with priority focus on interventions by funding a basic minimum package of services.

As at today, states that have passed laws establishing SSHIS are Lagos , Abia, Kwara, Delta, Ekiti, Kano and Bauchi, while Ogun, Enugu , Anambra and Ebonyi are at advanced stages with their laws being passed.

With Delta State already leading the pack as the first state in the country to implement a mandatory health insurance scheme, garnering over 112,169 registered enrollees within few months of starting the scheme, a result that has shown that right health insurance models can achieve results, THISDAY therefore sought audience with the Director General, Chief Executive Officer, Delta State Contributory Health Commission (DSCHC), Delta State, Dr. Ben Nkechika to know how their model has achieved success for them.

He said the Delta model instantly gained success because the governor, Senator Ifeanyi Okowa is well versed in how healthcare should ideally be run, coupled with his antecedent as the former Chairman, Senate Committee on Health, where he championed the health insurance programme at the federal level.

According to him, the scheme has commenced services in 63 secondary healthcare facilities for pregnant women and children under-five years with the transition of the free maternal and child health programme into the state before the end of October 2017 through partnership, especially in healthcare service disadvantaged areas, adding that as at 31st July this year, it has had a total of 26,905 pregnant women and 44,445 children under five years who have been registered and were receiving treatment budgeted and paid for by the government.

He said about 100 Primary Healthcare Centres (PHC) spread across the state have been considered appropriate to commence provision of service under the scheme in August 2017 and a quality of service improvement programmes has been initiated to achieve 100 PHCs through partnerships, especially in healthcare disadvantaged areas.

“The public sector workers in the formal sector group have signed up to be included in the scheme with the commencement of deduction of 1.75 per cent of their consolidated salary, while the government will contribute an equivalent 1.75 per cent on their behalf, and so far, over 49,000 public sector workers have been enrolled in the scheme.

“By next month we will be taking on the informal sector; that is the okada riders, market women and all that, so we will be mixing the pool until we have a large number, because it has to be a pool, and health insurance coverage works better with numbers. You know our model is mandatory by law, but because of the capacity gap in taking on everyone in from day one, we decided to segment it, and this will ensure at the end of the day we take in a mixed pool which is very critical for success,” he explained.

The CEO said the enrolment and payment of premium by the informal sector groups commenced this September, noting that premium of N7, 000 has been adopted after consideration and review of the actuary analysis report with focus on the affordability of the average family to ensure no one is left behind.
“For all these to happen within the short period that it did, we first determined key household demography and health seeking behaviour of Deltans to guide planning for the expanded health insurance coverage. We determined the current household spending on health, insurance coverage needs and willingness to pay for health insurance by Deltans.

“We also estimated the proportion of Delta State residents in the lowest socio-economic quintiles, to guide decisions on subsidy and or exemptions from payment. We then proceeded to assess the availability and capacity of health delivery facilities in Delta State to deliver proposed health insurance services
“We also assessed the readiness of health facilities to deliver proposed services across all 25 LGAs,” adding that after which, the state embarked on advocacy meetings with the Hospital Management Board, Primary Healthcare Development Agency, Private Healthcare Providers Association, LGA Chairmen, LGA PHC Coordinators, various formal and informal sector associations and other relevant stakeholders as a way of keying them into the vision of the governor on health insurance.”

Nkechika said for the programme to outlive the present administration of Governor Okowa, it was made part of the law that 0.55 per cent of the consolidated revenue of the state goes direct into health insurance; such that it won’t only exist at the mercy of subsequent governors. “We also had clear-cut directives on where we can source funds, even in the law; there is a clear-cut portfolio on where you can invest that money, so that you don’t put it in the place where it can be abused.

“For us to offer this coverage qualitatively, we realised that if we collect N7, 000 and spend about N4, 000 on administrative processes, it will become a problem, so we had to look within the civil service to find people that were competent to be trained to work in the commission as against bringing healthcare workers from out of town that becomes expensive to manage since they were already on the pay roll of the government, we made them the workforce, such that the N7, 000 being paid by enrollees can best serve the purpose.”

He said the agency also tried to digitalise and create systems that make bureaucracy minimal, “because bureaucracy is always very expensive, so we have partnered with Interswitch to give us technology solution that makes the process seamless. Like our premium, you can pay with a POS, from ATM and online. We made it in such a way to reduce the transaction cost associated with it.”

But with the Delta model already in top gear, what should NHIS do to grow the scheme in the country? Nkechika provides a guide. He said for NHIS to succeed, it should decentralise health insurance, provide support to the states and must let them be enthusiastic about domesticating their process, they’ve been doing that but it has not been thoroughly done.”

The Delta State Contributory Health Scheme has been awarded the 2017 Outstanding Healthcare Programme of the Year. The award was presented at the Nigerian Healthcare Excellence Award ceremony in recognition of the state’s outstanding service delivery in the field of healthcare in Nigeria and the State Supported Health Insurance Scheme.

The Programme Leader, Health in Africa Initiative and Lead Health Specialist, Khama Rogo, said the momentum towards Universal Health Coverage in Nigeria has significant implications for the rest of Africa” saying that “if for instance Lagos with its over 20 million population achieves or moves closer towards its UHC goals then that is the fifth largest economy of Africa and that will be one of the largest pools on the continent and comparable to some national pools.”

He mentioned that progress towards UHC by countries especially those running a federal structure like Nigeria needs to prioritise health in budgets, cannot afford to leave the poor behind and must necessarily ensure their participation through subsidisation of premiums, and a major advantage of the pools formed is the link to an explicit purchasing of care through public and private providers.

He argued that the development of SSHIS will allow the participation of private players to deliver care to a population that are normally left out and will increase consumer choice and even incentivise the movement of providers to areas not normally covered.

He urged states to learn from the early lessons of the Kwara State programme which has provided a template on how to deliver affordable and accessible quality care to poor citizens of Kwara State .

He believes that unlike Ghana which has successfully used the Value Added Tax to fund 75 per cent of the scheme, Nigeria ’s attempt to use the Basic Healthcare Provision Fund from at least one per cent of the Consolidate Revenue Fund of the federation account might be a significant edge for Nigeria .

“ Nigeria is a rich country you know and committing such resources to healthcare in an efficient manner is significant. The funds from the BHCPF through the SSHIS as a type of results-based intergovernmental resources allocation can be a game changer for improved healthcare delivery in Nigeria .”

He urged Nigerian states to learn from the examples of Kenya and Ghana to see how those countries have leveraged technology to fast track coverage of their programmes.