How Delta boosted enrollment into its health insurance scheme

Dr. Ben Nkechika is a Harvard trained health insurance expert and Director General/Chief Executive Officer (CEO) of the Delta State Contributory Health Commission (DSCHC). Nkechika, in this interview with The Guardian, among other things, disclosed how the Delta State Contributory Health Scheme (DSCHS) has been able to boost enrollment figures. He spoke to CHUKWUMA MUANYA.

What has been the challenges getting more enrollees on board DSCHS?
The Delta State Contributory Health Scheme (DSCHS) was established by the Delta State Contributory Health Commission (DSCHC) Bill, which was signed into law by the Governor of Delta State, Dr. Ifeanyi Okowa, on February 4, 2016.

The DSCHC has health plans for enrollees. The Equity Health Plan for the poor and vulnerable, the Formal Health Plan for workers on payroll, the Informal Health Plan for all others that are not in the Equity Health Plan and Formal Health Plan, and the Private Health Plan for those that require extra healthcare services on top of the Basic Healthcare Package.

We have done well with the Equity Health with over 832,964 enrollees and the Formal Health Plan with over 172,418 enrollees. Our biggest challenge has been with the Informal Health Plan with only 14,079 enrollees. Several efforts have been made through advocacy and sensitisation activities, for example, road shows, town hall meetings with various stakeholders, flyers, electronic and print media programme, social media etc. with minimal positive outcome.

We have developed a new strategy, which is beginning to show better outcomes. The strategy involves engaging the informal sector groups through their trade unions, cooperative societies, town unions, and premium payment incentives. Lack of trust in service delivery from the local healthcare facilities and the assumed narrative that paying upfront for healthcare equates to wanting healthcare challenges, has been found to be among the reasons for informal sector unwillingness to pay for health insurance. A mandatory health insurance system with incentives and sanctions for non-compliance and earmarked public funds to pay premium for those unable to pay and a commensurate revitalisation of quality primary healthcare service across the country will definitely boost enrollment figures in Nigeria. Rwanda and Ghana are good examples of such.

One of the major problems of National Health Insurance Scheme (NHIS) is resistance from workers in the formal sector. How are you tackling the situation?
The DSCHC strategically engaged with Labour at the conceptualisation stage for the Scheme. Several meetings were held with Labour leaders and at one such meeting; we got to know of their interest and ensured their interest was accommodated in our planning processes. Thus, Labour got involved in our planning and made valuable input and when we were ready to start, resistance was low. The only resistance we got was their fear for quality of healthcare service delivery from government hospitals, which we overcame by enlisting their choice private hospitals into the Scheme and enhancement of government hospital service delivery capacity.

Labour is still a critical support system for the DSCHS with a Labour team set up for quality of service monitoring as part of the DSCHC monitoring and evaluation process.

What lessons have you learnt from the challenges of NHIS?
The most important lesson learnt was ensuring the Delta State Contributory Health Scheme was mandatory for all residents of Delta State. NHIS has continued to provide technical support to the DSCHC, ensuring we learn from the challenges they have experienced and forge ahead with more vigour.

What will you do differently for DSCHS to succeed and outlive Dr. Ifeanyi Okowa’s administration?
The DSCHC at the beginning developed a Strategic Implementation Programme, which involved a Start-off Phase in 2017 to establish Start-off structures, a Sustainability Phase from 2018 to 2019 to establish systems that will sustain the Scheme processes for the long run and a Consolidation Phase from 2020 to 2021 to ensure consolidation of the sustainability systems established. We will commence the Continuity Phase of the Strategic Implementation Programme in 2022 to ensure continuity of the Scheme processes beyond the current administration of Dr. Ifeanyi Okowa, Governor of Delta State. The Continuity Phase involves getting the DSCHC ICT systems formidable and compliant with national and international best practices requirement, capacity development and enhancement activities for all DSCHC personnel and accredited HCF personnel, getting the people to take ownership of the Scheme through participatory engagements, creating a robust and interactive communication channel that will build and assure confidence in the Scheme by the people and building a stable financial base with significant Public Private Partnerships that will ensure financial autonomy.

Health financing is a big issue in Nigeria considering the country’s poor economic status. How are you navigating this obstacle?
We commenced to Scheme at a period when the state’s economy was at its poorest. This energised us to start prudent financial management processes to get best value for whatever funds were made available. Strategies to enhance revenue, conserve revenue and still ensure quality service delivery were put in place. We also built a robust reserve fund early and that helped us remain active during financially challenging times.

Sin Tax has been one of the recommendations on how to boost healthcare financing. What is your take on this? Do you have a better idea?
Taxing with incentives and resource management confidence building will boost healthcare financing in Nigeria. People need to trust and believe that any extra tax they are made to pay will deliver benefits to them. That is where I feel the challenge is. People don’t believe and trust that the system will utilise their tax funds properly. Thus willingness to pay is very poor. They will rather go to a caregiver to request for service and pay on the spot than pay upfront and not be sure if the healthcare service will actually deliver healthcare services when they need it.

What do we know about DSCHC’s collaborative relationship with UNICEF?
The DSCHS is the healthcare financing system established by the Delta State Government to ensure access to affordable and quality healthcare services for all residents of Delta State, irrespective of their socio-economic status and geographical location. The DSCHS is the main vehicle responsible for driving the aspiration of the Delta State Government towards the achievement of Universal Health Coverage by the year 2030.

Sequel to the DSCHC progress towards achieving UHC through expanding health insurance coverage for the vulnerable population – especially pregnant women and children under five years, UNICEF has established a partnership relationship with the DSCHC to enhance the Delta State Model as a template for Expanding Health Insurance Coverage at the sub-national level. Nigeria is estimated to be one of three countries, along with India and the Democratic Republic of Congo, to experience the most significant increase in people under the poverty line due to COVID-19 alongside increases in a range of multi-dimensional deprivations, including food insecurity and malnutrition.

As part of this collaborative effort between the DSCHC and United Nations Children Fund (UNICEF), a Position Paper on the Expanding Health Insurance Coverage of health in Nigeria was developed relating the Delta State Model to lessons from Rwanda, Philippines, and Malaysia. Following the Position Paper was a review of the document at a Stakeholders Policy Dialogue session, which took place penultimate week at the DSCHC office at Asaba.

What was the gathering of health professionals in the dialogue session about?
The Delta State contributory Health commission has affirmed since 2017 when it commenced till date and has achieved quite a lot. Most significant is the fact that we have the highest number of health insurance coverage among all the states in Nigeria, particularly, significant coverage from the poor and vulnerable residents of Delta States.

In view of that, UNICEF has taken interest in the achievements of the commission, done a research review on it, and most of our service delivery processes are comparable to safe delivery processes of other notable countries that have achieved universal health coverage. So, with that mindset, we know what has happened in Rwanda, Malaysia, the Philippines and other countries that have achieved universal health coverage.

So, UNICEF having that realisation that our systems and our processes are kind of in line with what those other countries have done, have seen that Delta State is on a good pathway and a good trajectory towards achieving universal health coverage and by the year 2030. So, with that position paper was initiated to be developed for putting out what the Delta State model is doing a paper review report on it and that position paper is ready and UNICEF also felt that before they take on the position paper as a model for expanding versatile universal health coverage in Nigeria that it was good they kept in expert policy makers, private sector, service providers. Basically, getting a stakeholder policy dialogue system to review that policy position paper, critique it, analyse it and look at all the various dynamics and dimensions of enhancing universal health coverage particularly in vulnerable areas ensuring that the demand side health system and the supply side healthcare provider system interacts for the benefit of residents of Delta State. So, today’s policy dialogue session is to create that opportunity to critique, analyse, review and come up with a more cohesive and dynamic position paper that UNICEF now intends to use for its expansion advocacy programme for achieving universal health coverage in Nigeria.

As the advocate of the enrollee, what are you doing to ensure effective service to the enrollees?
So, the health insurance programme basically demands healthcare service on behalf of the people. And that demand is implemented through a purchase of health care services from the healthcare providers. So, that is why health insurance is on the demand side while the healthcare provider is the supply side. So, the health insurance registers people into the Scheme, building the ICT or whatever dynamics is required, get the people to select the facilities they want and then send the names of those released to the facility.

That person can actually see a patient, check the blood pressure, take the temperature, check other vital signs as a basic minimum but that facility cannot provide any service beyond what the community extension health worker is recognised to prescribe. So, automatically you have to refer.

Another primary healthcare centre that can provide a higher level of care, which is now level two, or you refer to secondary healthcare facility if the service requirement is a secondary healthcare service. So, for everybody that receives a patient, you provide a basic care. If the care is beyond your capacity, we will know cause your certification will show.