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Taking pre-paid, ‘free’ health services to far-flung underserved communities

By Chukwuma Muanya
16 September 2022   |   3:29 am
Health, stakeholders say, is one of most expensive basic necessities of life. Several reports have shown that less than 20 per cent of Primary Health Care (PHC) centres in Nigeria are functional and more than 80 per cent of these facilities..

Mothers have their babies vaccinated at the Primary Healthcare Centre, Maraba, in Karu, Nigeria.PHOTO: DOMINIC CHAVEZ/The Global Financing Facility

Health, stakeholders say, is one of most expensive basic necessities of life. Several reports have shown that less than 20 per cent of Primary Health Care (PHC) centres in Nigeria are functional and more than 80 per cent of these facilities do not have doctors or nurses, just Community Health Extension Workers (CHEWs).

Unfortunately, most of the centres are in areas without basic amenities, which will encourage doctors or nurses to live in such places. In fact, to access some PHCs, you have to travel for hours. In the Niger Delta Region, you have to go through difficult and unsecured creeks by boats with hired security. The situation is no different in Borno State and parts of Northwest Nigeria.

Also, the centres compete with Traditional Medicine Practitioners (TMPs) and Traditional Birth Attendants (TBAs) for the many patients in the localities. Painfully, most residents and natives of communities where the PHC are situated prefer the TMPs and TBAs because they are not only cheaper, but also, more accessible and culturally acceptable.

Indeed, providing access to equitable, affordable and quality healthcare for citizens has been a significant challenge for many countries. This challenge has become more daunting with the COVID-19 pandemic.

This concern has also led to mainstreaming the concept of universal health coverage (UHC) into the global health agenda as prescribed in the United Nations Sustainable Development Goals (SDGs) in 2015.

The Guardian gathered that healthcare financing indicators reveal that the country lags behind in most fields. Consequently, governments across are engaging in reforms to improve their health systems.

According to recent figures from the World Bank, financial barriers to access health care exist in Nigeria due to inadequate investment, poor funding and lack of coverage by prepayment arrangements.

The Guardian checks reveal that health expenditure as a percentage of gross domestic product (GDP) remains at 3.8 per cent, and out-of-pocket expenditure of 76.6 per cent is one of the highest rates globally.

Also, the World Bank said coverage with prepayment mechanisms and social safety nets are suboptimal at five per cent and less than two per cent, respectively. This is further worsened by pervasive poverty and income inequality, making access to quality healthcare services through out-of-pocket payments difficult for citizens in Nigeria.

According to a statement from the Federal Ministry of Health, before COVID-19, just 4.4 per cent of the population was covered by at least one form of social benefit or assistance. The pandemic has further worsened these concerns.

The Guardian gathered that Nigeria, India and the Democratic Republic of Congo are expected to experience the most significant increase in people living under the poverty line due to COVID-19.

The attainment of UHC by 2030 is important to combat the increasing challenges of poor health outcomes, with maternal and neonatal mortality in the country being persistently high and accounting for 10 per cent of worldwide maternal deaths.

From NHIS to NHIA, access to health care still a dream
NIGERIA established its National Health Insurance Scheme (NHIS) in 1999, with a mandate to attain UHC. However, since then, coverage has been marginal at less than five per cent.

Currently, Nigeria is considering mandatory prepayment mechanism to tackle its health financing challenges and stem its poor performance. This strategy aligns with the broader view that introducing mandatory prepayment systems and subsidies for the poor and vulnerable will help the country attain UHC.

Though the country has achieved this by its recent signing into law, the National Health Insurance Authority (NHIA) to replace the NHIS, there is still not aggressive implementation and enforcement.

To further strengthen the drive to UHC, the Nigerian government established the Basic Health Care Provision Fund (BHCPF) as an earmarked fund for the effective delivery of healthcare services for all Nigerians. However, since its commencement in 2019, its implementation by the NHIS as a parallel programme with state health insurance programmes has made effective implementation difficult.

Some of the noted difficulties include: Variations in benefit packages, enrolment processes, tariffs, billing/claims management, and information and communication technology (ICT) infrastructure harmonisation. Thus, policy and programmatic divergence persists within the 36 states and the Federal Capital Territory.

As a panacea for the increasing challenges, an initiative known as Health Insurance Under One Roof has been introduced as a mechanism for coordination, regulation and integration within the health insurance ecosystem in Nigeria. Despite these efforts, the current coverage level through health insurance remains low.

Health experts, critics and watchers of events in the sector say the country needs to redouble and re-evaluate its efforts and strategies to be on track for achieving UHC. Suffice to say that countries making progress on the journey to UHC have implemented context-specific models to finance citizens’ healthcare, especially of the poor and vulnerable.

Working models
IN an effort to expand the access to services to the very rural hard to reach and underserved communities, especially the communities where facilities have been built, but now abandoned and non-functional, the Delta State Contributory Health Commission (DSCHC) in partnership with PharmAcces and Bank of Industry (BoI), embarked on the implementation of an innovative project, Access to Finance programme.

The Delta State government was, last week, commended by the World Bank, Federal Ministry of Health, the Senate and The Netherlands for achieving 25 per cent UHC through its Delta State Access to Finance Programme and the mandatory DSCHS.

These bodies said the programme is capable of reversing brain drain in the health sector, increase enrollment in health insurance scheme and ensure attainment of UHC by 2030.

Country Director, PharmAccess Foundation, Njide Ndili, at the Impact Study Dissemination of the Delta State Access to Finance Programme with theme ‘Primary Healthcare Revitalisation via Public Private Partnership’, said: “We are trying to find a way to make healthcare accessible for those at the lowest levels. The Dutch government is supporting us to make health market work. We are using technology to track the funds and the utilisation, which is the critical success factor. We did not get it right at the beginning but we persevered.”

According to the chairman, DSCHC, Dr. Isaac Akpoveta, the programme involves a needs assessment, an implementation framework and a product paper for its deployment.

A needs assessment is the process of identifying and determining how to bridge the gap between an organisation’s current and desired state. He said an advert was placed in two national newspapers for interested Healthcare Providers (HPs) to indicate interest.

Akpoveta said a due diligence appraisal along with a Credit Review was done by the PharmAccess Foundation and BoI to confirm the capacity and capability of the HPs to be engaged.

He pointed out that there are six HPs from different parts of the country providing healthcare services in 15 rural hard to reach community healthcare facilities in Delta State under this Public Private Partnership (PPP) arrangement and the health outcomes of these previously underserved communities have improved, tremendously.

Akpoveta added: “We have been able to reactivate abandoned and moribund health facilities through PPP. We have been able to reach 1.2 million enrollees that are about 25 per cent of the Delta State population, deploying unique and innovative programme such as access to finance project, which is financially managed by Bank of Industry.

“One major benefit of this programme is the reversal of brain drain in Delta State workforce. The Delta State government tapped into the private sector to recruit the Chairman and Director General/CEO of DSCHC.”

Secretary to State Government (SSG), Mr. Patrick Uka, said this signifies, in part, a smart agenda. “This is also a healthcare financing mechanism to ensure availability of adequate resources to deploy healthcare especially for the poor and vulnerable. We have covered 1.2 million that is about 20 per cent coverage. We have won the award for Best Performing State Health Insurance in Nigeria several times,” he said.

Director General, National Health Insurance Authority (NHIA), Prof. Nasir Sambo, said: “One thing the new NHIA has achieved is the establishment of vulnerable group funds for the down trodden. Before the NHIA was signed into law, the NHIS had made attempt. Delta State stands out due to the exemplary leadership of Okowa and the tenacity of Akpoveta and Nkechika. The NHIS started innovative health insurance under one roof. Another thing that makes the DSCHC stand out is the PPP.”

President of the Healthcare Federation of Nigeria (HFN), Pamela Ajayi, said: “We are committed to providing Nigerians with UHC. We continue to work with PharmAccess and others. We are willing to work with any state that is willing to emulate this wonderful innovation.”

For Senior Health Specialist, World Bank, Dr. Olumide Okunola, “Nigeria has delayed UHC. UHC is when every citizen has access for affordable and quality health care without suffering catastrophic economic situation. It is good to see innovation taken to scale in some parts of this country- in Delta State.”

Okunola believes the country still has problem in the area of demand and supply side of healthcare services. To him, thhings are happening more on the demand side, where there are people demanding care than on the supply side. “So, the problem is functionality. So, we are here to celebrate how Delta State used policy to change the trajectory. So, we have an innovative framework which Delta State has imbibed.”

Okunola said the Impact Study shares explicit experiences from the DSCHS Equity Health Plan for the poor and vulnerable, showing that using the above-stated approach significantly impacts population health. “We therefore recommend adopting the DSCHS model for health insurance coverage expansion across Nigeria with a significant focus on poor and vulnerable populations,” he said.

The study showed only 20 per cent of Primary Health Care (PHC) centres are functional at the moment. It showed that Delta State has been able to reactivate abandoned and moribund PGC facilities through PPP by deploying unique and innovative programme such as access to finance with the support of PharmAccess and the government of The Netherlands.

Minister of State for Health, Hon Joseph N. Ekumankama, said: “Access to essential healthcare is an integral part of social protection, which refers to the policies and programmes aimed at ensuring a life of dignity and removal of financial barriers to accessing essential social services- including primary health care- throughout the life cycle.

“The successes recorded by the DSCHS demonstrate the critical role of strong political support from the government and elaborate stakeholder engagement for the successful rollout of any social health protection programme,” Ekumankama said.

Chairman, Senate Committee on Health, Dr. Ibrahim Oloriegbe, said: “When Okowa was Chairman Senate Committee on Health, the National Health Act 2004 was passed and signed into law. He has pioneered so many things. To reach UHC, we need access to finance. This programme has shown us innovative and sustainable way of doing things.”

While commending the programme, Consultant, PharmAccess, Mr. Sunday Mgbejume, said: “Only 20 per cent of PHC centres in Nigeria are functional at the moment. It is something important that policy makers should look at.

“In this new concept, government remains owners and the private providers helping us to operate it. In all, 15 hospitals facilities have been taken up. There are six private operators from HFN helping to drive the model.

“Major value of the programme include revamping of the dysfunctional and moribund PHC centres; ensuring in the medium and long term, the private parties will reap returns on investments; and it is possible to achieve zero infant mortality.

“People now have 24 hours of care. I visited the nooks and crannies of Delta State and I spoke to local women.”
Mgbejume, however, said it is not yet a 100 per cent initiative as it were but they have done remarkably well. He said a proper feasibility study should be conducted to know what the specific needs are.

Consul General, Embassy of the Netherlands, Lagos, Mr. Michel Deelen, said the project has shown that “if we sit with stakeholders, we will achieve so much.”

The Managing Director, Medical Credit Fund of the Netherlands, Dr. Arjan Poels, also noted that $150 million have been deployed in six African countries including Nigeria for the actualisation of this programme. He, however, added: “This is something that is completely different. It has been excellent model in upgrading PHC centres. I think this model should be copied in other parts of Nigeria. The goal is to increase and improve healthcare throughout Africa.”

While urging DSCHC to try and retain the doctors since many of the communities are willing to accommodate them, former Deputy Governor of Delta State, Chief Ben Elue, called on providers to make sure patients get the recommended drugs from the hospitals such that they would not be exposed to fake and substandard drugs.

A beneficiary, who gave his name as Mr. Nelson, said, “mortality has reduced. We don’t have to travel to Warri for four hours to access medical care, especially surgeries.”

However, a provider, Dr. Ngozi Onyia, said it is not yet Eldorado. According to him, there is still delayed payment of claims on what was spent on treatment of patients.

Onyia insisted there is also inflation on the cost of drugs, saying a drug bought for N150 today, could go for N750 in two weeks, making it almost impossible to meet up.

“Capitation is the best option but it has to be well priced. You cannot fix capitation at N500 per patient; it is unrealistic. The programme is riding on private sector efficiency, leveraging on government infrastructure.”

On the issue of claims management, Director General and Chief Executive Officer (CEO), Dr. Ben Nkechika, said: “The patient is registered electronically and claim made electronically. This removes the issue of corruption and inflation of figures. We have had manpower challenges. It is a dynamic process and nobody is perfect. One of our key points is that we treat everyone on equal basis. We understand that most providers have not broken even.”

17 states shun universal health insurance scheme
ALTHOUGH the Director General, NHIA, Prof. Mohammed Sambo, had told journalists that about 36 states and Federal Capital Territory (FCT) have passed their own laws, independent reports showed that 17 of them shunned universal health insurance scheme.

There are, however, indications that only 19 states are at different stages of implementing Universal Health Coverages (UHC) through the establishment of health insurance schemes, while 17 states have no plan to join 19 years after the launch of the scheme in Nigeria.

“So, we now have 37 states that have started the implementation of the basic healthcare provision fund and based on the resources that we have delivered to them, they have been able to cover a lot of ground in terms of numbers. So if you want to get the actual number, it requires aggregation,” Sambo said.

Head, Medical Services, Leadway Health, Temitope Falaiye, in a paper, said Anambra, Delta and Lagos states have, particularly, made significant progress in enrollment of individuals on the scheme.

Lagos State Health Management Agency (LASHMA) was established by the enabling act No. 14 of 25 May 2015 and registered in Lagos State of Nigeria (Official Gazette No. 32, Vol. 48) dated June 5, 2015 to ensure that all residents of Lagos State including Public Servants have access to affordable and quality Health Care. Through the Scheme, people living in Lagos can be protected from financial distress resulting from huge medical bills.

Law establishing the Anambra State Health Insurance Scheme (ASHIS) came in 2016, with the mandate to provide access to quality, affordable and efficient health services for every resident in the State. The scheme was officially launched by the state government in September 2018 to improve both physical and financial access to quality healthcare services for all residents toward achieving UHC by the year 2030.

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