How to improve health insurance coverage in Nigeria, by Ukiri

Ms. Adesimbo Ukiri, is the Chief Executive Officer (CEO) and Director of Avon Healthcare Limited, a leading Health Maintenance Organisation (HMO) accredited by the National Health Insurance Scheme (NHIS). Ukiri has over 20 years’ experience across a number of sectors including Banking, Telecommunications and Health. She served as Acting Managing Director of Hygeia HMO; Partner of ARG Strategy & Marketing Consulting; Head of Division Sales, Vmobile. She is a graduate of Law from Obafemi Awolowo University (OAU) Ife, Osun State, and is a Sloan Fellow of London Business School; where she obtained an MSc in Management. Ukiri, in an exclusive interview with The Guardian, said among other things that embracing the Big Data concept and having a legislation making health insurance compulsory could be used to achieve universal access to health insurance in Nigeria and make the NHIS more efficient. CHUKWUMA MUANYA and VICTORIA NJOKU write.

The drive of the NHIS and indeed most nation’s health insurance programme is for universal coverage. Unfortunately, less than 10 percent of Nigerians have a form of health insurance. What are you doing to bridge this gap? How many Nigerians are enrolled with you and how many do you have the capacity to manage? What is your target enrollees, say by end of next year?

The state of the nation or lack of progress we have made as a nation in terms of universal health coverage is a source of great distress to people like me because we see the opportunities and we know that it is possible for us to achieve as a nation but unfortunately we have been unable to do so and you are quite right to say ten percent, other people will say far less than 10 percent, some will say it’s quite five percent, some will say it is four percent or even 10 but it is still dismal. It is still highly disappointing. It has got to be a collaborative effort and the leadership has to come from the top and the first and most important thing the industry craves for is to have a regulator that is able to put the right framework in place, to monitor operators, to make sure the ecosystem actually works. The other thing we also crave for is to have a legislation that makes it compulsory for every employer of labour to ensure that the workers have health insurance.

Now the current law we have is an Act, which just states that a company with over ten people as employees may make provision for health insurance. We want it to be mandatory. We believe that when it is mandatory we will see the same kind of response as we are seeing in pensions sector happening with us in health insurance, and we think health insurance is just as important if not more important than pension. So these are the things we believe that if we can have leadership right from the federal government level, putting the necessary legislation in place, having a strong and effective regulator, then the sky will be the limit.

A lot will depend on this regulatory environment we have discussed but we have the capacity to manage enrollees in millions, so nothing stops us from managing ten million enrollees if there is need to. We have invested heavily in the Information Technology (IT) as a backbone that can help us scale up. So really, with the IT system we have, whether you are managing a hundred thousand or managing ten million, it is more or less the same thing. And definitely, we might need to have a few more members of staff just because of the interface, we might need to expand our call center as well but by and large, most, if not all of the processes that drive what we do are technologically based.

You have this concept about Big Data. Where does it come in the efforts towards universal health coverage?

Data is king and we are discovering more and more data in this industry and asking about how to bridge the gap. The first and most important thing is to come up with products and services people actually want and are willing to pay for. So it is to come up with products and services that are consumer-centric because right now across the industry, you will see that many of the products are typically the same thing, we just call them different names-platinum, gold, silver, bronze and almost all products you see will fit into one of these four categories. Nobody is ready to be creative and you cannot blame him or her because they will be groping in the dark without data.

What medical data will do is to ensure patterns, frequencies, equivalents and it is only after you see all that that you can begin to design products to fit into target segments you have identified based on utilization pattern, based on disease pattern as well and also to price it appropriately because right now, one would see it that many people who cannot see the products they need in the products that are available, they end up buying products that have some certain services that probably may not be required. So the ability to use data to really understand what different segment of our society needs so that they do not have to pay for more than they will require.
There is something that really drives us in the quest for data even at the lowest level.
It helps us to appropriately price the hospitals because we are able to see what services, what diagnostics, what drugs, what treatments people are requiring and what funding, then we can discuss with hospitals who can then forward plans. We can have pricing tariffs that are reflective of what is happening. We can also do what is called ‘commissioning’; that grade the hospitals based on a number of services.
We can actually pay hospitals in advance and make the cash flow of hospitals better and improve the entire experience that people will have across the healthcare chain. So whether they are going into hospitals or into diagnostic centres to do a test, the fact that you have this data makes it possible for the flow of funds from one facility to the other, to be seamless, to be such that, you know, cash flow does not become a problem for them.

Has the NHIS bought into the concept considering the fact that we do not have data for most health indices in the country? How is the concept going to work?

I think there will certainly be some data sitting on the NHIS depository. But the question is how king is the data? How robust is the data? How granular is the data? There is definitely a lot of data in the system. Do not forget that NHIS has been in existence for over ten years now and they have the largest number of enrollees in the country.

Federal civil servants all make up six million of the seven million or 7.5 million enrollees that we say we have in this country. So over 90 percent of Nigerians in the formal sector are covered under NHIS formal sector plan which federal servants use. So the data of their utilization or usage over these years must be sitting with the NHIS. How do we use this data now to further our ambition, design proper products, ensure proper pricing and to have products that are really relevant to the needs of different segments of the market; not a situation where one product is expected to carter for all everybody. Those are the key questions.

How do we use those data also to appropriately price hospitals and how do we use data as well to appropriately price the end products consumers? Those are the kind of issues we should tackle.

What have been your major challenges towards delivering optimal health care to Nigerians as an HMO?

I would say one of the key challenges is the level of variability in quality and standards across hospitals. There is such a wide difference depending on which hospital, in which town, in which state: Lack of standardization across hospitals, lack of an accreditation system in this country that independently assists and grades hospitals. That is a problem. Because if we had that, then it is easier to pay hospitals in accordance with the level we have reached. If we also have that, then it is easier to have another institution that would ensure monetary and quality standards in hospitals. We are doing it right now but it is a heavy burden to bear. Each HMO does it independently, so we have a quality assurance department and we have mega professionals, doctors and nurses. Before a hospital joins our network, there is an accreditation process, they go to visit the premises, they look at their processes, and they look at what doctors they have, so we actually accredit hospitals for what we have adjudged them to be capable of doing, and the right quality.

So some hospitals were accredited for only general practices and outpatient services. We accredit some hospitals for obstetrics and gynaecology because we have seen they have a resident gynaecologists and resident physicians. So we accredit some hospitals for orthopaedics because we know they have an orthopaedic surgeon and once we have accredited the hospital, we continue with a quality assurance programme to ensure that they do not fall below what we have accredited them for.

But it is a huge problem to bear. It will be great if as a great country we had an independent body that monitored quality standards across hospitals. So that is one of the challenges that we have. There is such a wide variance between the standard you get depending on the hospital you are working with. We have our tools, we have our resources but it is still a challenge because you can imagine across the country we relate with over a thousand hospitals and healthcare facilities. How many staff am I going to have that are going to be able to visit over a thousand hospitals across the country.

Another challenge we have is that the market has not grown; there is what we call ‘unhealthy competition’. This unhealthy competition is not only due to the fact that the market has not grown substantially but also due to the fact that there is lack of availability of data to influence product design and pricing, so HMO operates within the market, feel themselves put under pressure to continuously underprice and undercut and that inevitably affects their details to pay hospitals and pay them well. It is inevitable that the quality of service the hospital will render to HMOs enrollees who come to their facilities will then affect how much price the end user is willing to pay or whether the end user is willing to buy the product as well. So those are key challenges.