Achieving community health insurance fund development goals in Nigeria

CONTINUED FROM Tuesday, April 28

In 2005, June 6, the formal sector of Social Health Insurance Scheme was flagged-off by Chief Olusegun Obasanjo– President of the Federal Republic of Nigeria, as at today, the scheme has covered all the federal ministries, parastatals and agencies, the Nigerian Police and the Armed Forces. It is now firmly established in private organisations.

Objectives of NHIS are mainly to ensure that every Nigerian has access to good healthcare services.

The key provisions of CAP 42 of the Laws of Federal Republic of Nigeria are that an employer who has up to ten employees may contribute to the scheme, 10 per cent of salary by the employer and five per cent by the employee. The four major stakeholders are employer, employee, the provider, and the Health Maintenance Organisation (HMO).

Healthcare providers are primary and secondary in category. The disease conditions are also categorised. The HMO’s are the operators of the scheme while the government agencies (NHIS) serve as regulators.
Provider Primary
Secondary Diseases
Tertiary Treatment`

Private Health Insurance Scheme has gotten various benefit packages which the company can choose from, that is, Silver, Gold, Platinum, and Diamond.

Resource Mobilisation is followed by a pattern of disbursement, that is, capitation, fee-for-service (FFS), administration and reserve funds.

Treatment is given through a network of providers. All have codes and their specialisations are noted.

There are some diseases or management entities that are classified as exclusions – many of them have no predeterminable end point.

There are disadvantages of the former system fee-for-service, out of pocket.

There are a lot of benefits of the National Health Insurance Scheme, the most important is “Resources Mobilisation” and Cross-Subsidisation.

The most important psychological benefit of Health Insurance is Enrollee Empowerment – OS Syndrome is not permitted in NHIS. A card carrier receives health care in a recognised health provider institution. For enrollees, strike action is not a barrier to accessing health care.
Community Health Insurance Scheme (CHIS)

Resource mobilisation and benefit package in CHIS
The benefit package should be targeted towards the greatest killer diseases in the country.

The major killer conditions in Nigeria today are malaria, road traffic accident, and HIV/AIDS. For children and many adults, enteric fever should be added and then bronchopneumonia. For women, complications of pregnancy and childbirth are major causative factors. Therefore, haemorrhage, obstructed labour will have to be taken care of.

In terms of resources mobilisation, it is my suggestion that the three tiers of government should be ready to support this course by a sum of N100 per enrollee per month. Every enrollee should also be ready to pay N100 per month. These should be pooled together and put at designated bank at the local council where the World Health Organisation is located.

It should be made clear that it is only when the enrollee has paid N100 that the contribution will be multiplied by four, the additional input coming from the local council, state and federal governments. Even the hundred naira can be paid for the enrollee by any of the tiers of government or relatives in Diaspora. The following benefit package should be guaranteed:

Malaria – Preventive and Curative
Enteric Fever – Typhoid
Bronchopneumonia
ANC, Pregnancy and Deliveries including Caesarean Section
Road Traffic accident

The contributions from the federal, states and local councils should be deducted at source and paid to the accredited bank in that local council.

Effectively, each enrollee will be insured with N400 x 12 = N4, 800 per year, and each health promoter’s association should be about 500 in number. This is lodged into Community Health Insurance Fund Account. Standard treatment regimes should be established for the above, cost actuarially and standardised. HIV/AIDS is squarely under NACA – National Agency for the Control of AIDS. This N100 is the minimum registrable sum, however, communities may decide to pay more in other to take care of other diseases like hypertension, diabetes and arthritis. It is also within the jurisdiction of the executive committee to grant coverage to chronically invalid people in their communities, if the amount in the Community Health Insurance Fund (CHIF) can cope.

The scheme does not in anyway nullify whatever existing health programmes that have been put in place by the various governments and NGO, but inculcates a fundamental philosophy that health is a habit, not an act, and at any point in time, health is a right not a privilege.

The goal of the CHIS is to build a micro or miniature tertiary centre where some operations can be performed, for example, herniorrhaphy, Ceasarean section and salpingectomy (Awojobi, pub; Obembe 2000).

It should actually function as a ‘‘colony” of a Teaching Hospital, so that if any consultant decides to work there, he can continue to publish and attain professorship in record time because there are more materials in the community, and community will be empowered to negotiate and pay for such services under Public Private Partnership arrangement. The contract between the consultant and the relevant university is intact.

Environmental sanitation should be incorporated into the Community Health Insurance Scheme – members of the Executive Committee should go around in turns and those who refuse to clear their refuse should be made to pay “fines”. These ‘‘fines” must be paid into the CHIF. Different quarters in the community should be awarded prices for coming first in environmental cleanliness, so that ‘‘cleanliness becomes a culture” and not an instrument of coercion or harassment as witnessed during the First Republic.

Every association – Health Promoters Association (HPA) must be registered and given a code number, because the relatives in town and overseas can conveniently insure their relatives by sending money home to the CHIF and listing their names. The account of the CHIF shall be audited in line with the regulations of the Corporate Affairs Commission and the National Health Insurance Scheme.

The healthcare providers shall also be chosen by the community. The community is free to choose either government or private providers provided they shall comply with the actuarial pricing which will be released by NHIS from time to time. For purpose of record keeping, accountability and documentation, the health care providers, either primary or secondary must meet the criteria already approved by the NHIS. Details of these can be worked out from time to time.

All insured enrollees should carry their Enrollee Access Card, which should indicate the blood group (ABO), genotype, and Rhesus Status (Rh). This of course implies that on entering the scheme, an enrollee is already aware of his genetic composition in terms of Heamoglobinopathy.

The fund should be strictly geared towards promoting health and not for erection or refurbishing buildings. The accommodation that the inhabitants of the town are using can be modified or renovated to accommodate the providers, if they are not resident in the locality.

The World Health Organisation (WHO) is the building block or cornerstone supporting the CHIS

The Royal Father, the traditional ruler, or community leader that is resident in the ward shall be the patron of the WHO. He oversees the health of the environment/community. In many towns and villages, spaces may be adaptable in their palace for outpatient care purposes. The traditional institutions are our heritage and must be respected, modernised, and made relevant to current trends. Despite all the incursions of western forms of governance, the fact remains unassailable that they are the first port of call when problems, particularly when health related problems, arise in their domain.

The Health Advisory Council is constituted as follows:
Representative of Royal Father – Chairman
College of Medicine
Teaching Hospital
State Government
Local Government
NHIS
HMO
President
Secretary Health Promoters Association
Treasurer
Public Interest
NCP

The function of the HAC will mainly be geared towards mobilisation of resources and the fund so collected must be deposited in the community health insurance fund. The sources include premium paid by household enrollees, subsidies from local, state and federal governments, NGO and relations in the Diaspora. The quorum shall be 50 per cent of council membership.

There shall also be a judicial arm of the HAC made up of:

Rep of Royal Father or Community leader
President HPA

Health care provider registered and resident in the community

This body will be required to try offences related to environmental abuse, refuse and sewage disposal, and personal hygiene. The proceeds from the fines to go to CHIF. The accounting officer remains the HMO and must make regular returns to the HAC and NHIS.

Health Promoters Association
This is a body consisting of the constituent household heads. They pass health information to and from the HAC. They elect their own executive who in turn undertakes regular environmental inspection of the community compounds as a weekly exercise. They are in charge of the day to day running of the organisation, that is, accommodation, office space for clinic, theatres and immunisation centres. In any emergency they are to ensure that the patient is transported speedily to the healthcare provider with whom the patient is registered. They are also expected to arrange the payment of the medical bill from the CHIF.

Household Enrollees
Everybody living in a household is expected to enroll with the CHIS. But in circumstances where there are more families in a household or compound, they will be required to elect among themselves the leader that will represent them at the Health Promoters Association
Millennium Development Goals (MDGs)

The Fundamental Right to health was codified in the Universal declaration of Human Rights of the United Nations General Assembly in 1948. World Conference of Human Rights in Tehran, Iran 1968, in Cairo, Egypt 1994. All these conferences articulated the need for conceptual framework to address health issues, eradicate poverty, and improve quality of life in 192 countries of the United Nations.

Progress towards achieving (MDGS)
In recent years, the Millennium Development Goals (MDGS) have become a quantitative set of targets for poverty reduction and improvement of health, education, gender equality, the environment and other aspect of human development.

oing through the targeted areas of improvement, item three, four, five, six, seven can be improved upon directly by strengthening the Community Health Insurance Scheme. But going in serial order, the MDG can be achieved in the following ways.
Poverty, ignorance, and disease always constitute vicious cycle which has to be broken. But when disease is removed, the individual can work, become economically productive and can liberate himself from poverty.
Universal Primary Education can only succeed when the children are free from the scourge and burden of disease.

Item three, four, five, six, seven are directly related to health. Economic and gender empowerment is guaranteed once every pregnant woman is insured. She can confidently go to a registered facility to deliver without any fear or hospital bills. Reduction of child mortality is directly effected since malaria, enteric fever and bronchopneumonia are covered.

The three major causes of maternal mortality can be treated – haemorrhage, infections (malaria) and prolonged labour. These can be managed under skilled supervision – concept of prophylactic obstetrics.

Environmental sanitation will reduce malaria, enteric fever and improve community health.

The improvement in all the six target goals will be an encouragement for donor countries to increase official development assistance.

According to the last estimate of maternal mortality for 1995 alone, 500,000 women die annually during pregnancy and childbirth, most of them from conditions that could be prevented or treated in well equipped medical facilities. For the reason, maternal mortality is very low in Latin American and East European regions where skilled attendants are available with equipped medical facilities, but very high in African and South Asia regions where many of the attendants are unskilled and facilities are lacking in equipment.

Conclusion
Aristotle the great philosopher once said: ‘‘We are what we repeatedly do, excellence then is not an act but a habit.” So Health should cease to be an Act but a Habit. Health should cease to be a privilege but a right. It is not the years in your life that matters but the life in your years. Let us all carry the message of community health insurance to our people. The task before us may be Herculean but not insurmountable.

Case report
Two shoe salesmen were sent overseas to scout for new markets, their first stop was a country where everyone was barefooted. The first salesman sent a telegram to the office saying, ‘‘leaving tomorrow no one wears shoe here.” The second salesman’s telegram was very different. He said, ‘‘great potential market, no competition!”

The opportunities at the community level are enormous and untapped. The only way to gain access to such opportunities is to open up the sector to adequate health care which Community Health Insurance Scheme is geared to achieve. In fact, borrowing from the politicians the definition of Democracy, we in the health sector can define community health insurance as: Health of the people, by the people and for the people.

Summary
If Nigeria is to be among the best 20 economies of the world by the year 2020, the health indices must be improved commensurably, for example, the Maternal Mortality Rate (MMR) must be reduced from four to two digits. The conceptual framework that guarantees uniformity and sustainability has to be put in place. This is community health insurance scheme operating through the World Health Organisations. With resources mobilisation and risk sharing, out of pocket payment at the point of encounter will be abolished. As a result, the basic health standard of the populace will be improved. This is the fundamental health requirement for achieving the millennium development goals.