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Making health insurance work in Nigeria

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Minister of Health, Prof Isaac Adewole

The National Health Insurance Scheme (NHIS) was kick started in 2005 by the General Olusegun Obasanjo administration to help the country achieve Universal Health Coverage (UHC).

Unfortunately, after thirteen years less than five million Nigerians are registered with the Scheme.

These numbers are mostly Nigerians in the Federal Civil Service. The informal sector is not yet captured.

However, some individuals and organization has some form of health insurance by subscribing to a package from the many Health Maintenance Organisations (HMOs) registered and regulated by the NHIS.

It is estimated that over seven million Nigerians are captured under this arrangement.

This means that over 160 million people still pay out-of-pocket for medical expenses, which is against the dictates of a health insurance scheme.

The overarching idea behind a health insurance scheme is to improve the health of all Nigerians at an affordable cost.

But The Guardian investigation revealed that this inability and ineffectiveness as well as the shroud of corruption that has covered the NHIS from its inception are major factors that have led to the call for the repeal of the NHIS Act and the enactment of a new Act in its place.

To reach more Nigerians with health insurance, States were encouraged to establish health insurance programmes. Kwara was the first State to establish a health insurance programme.

This has already resulted in a number of states such as Delta, Cross River, Lagos, Kano among others signing their state Health Insurance Acts into law.

Investigations revealed that another major constraint of the NHIS is that it is voluntary compared to the Delta State Contributory Health Scheme (DSCHS), which is mandatory.

However, there are efforts in the National Assembly to amend the NHIS Act and make it compulsory for all Nigerians like the programme in Delta State.

Little wonder within a year of its operation, the DSCHS was able to win an award in 2017 for the Outstanding Healthcare Programme of the Year at the Nigeria Healthcare Excellence Award ceremony and in 2018 also won an award as the State with the most people covered under its State Social health Insurance Scheme with focus on the poor and vulnerable population in Nigeria under the World Bank – Save A Million Lives Programme.

The Vice President of the Federal Republic of Nigeria, His Excellency Professor Yemi Osibanjo, presented this award.

Director General/Chief Executive Officer (CEO) of the Delta State Contributory Health Commission (DSCHC), which establishes and runs the DSCHS, Dr. Ben Nkechika, in a chat with journalists explained why the Scheme is working in an environment where the NHIS, ran by the Federal Government, has failed.

How have you been able to grow the Scheme in just twenty months?

Since its inception on January 1, 2017, over 300,000 residents of Delta State that include pregnant women, children under five years, public service workers and the informal sector have been enrolled into the Scheme with access to 225 public and private healthcare facilities accredited for the Scheme in Delta state.

The growth of the Scheme can be ascribed to a combination of factors that include the Governor’s strong political will, strategic planning, prudent resource management and the support from Deltans.

At the 58th National Council on Health meeting in March 2015, one of the resolutions passed was for all States in Nigeria to establish a State Supported Health Insurance (SSHIS) programme as a decentralization strategy to enhance and encourage Universal Health Coverage (UHC) across the country.

Senator Dr. Ifeanyi Okowa made establishing a State supported health insurance scheme for all residents of Delta state a cardinal programme of his new administration.

He had gone up through the State bureaucracy and political strata to become the Commissioner of Health in Delta State, Secretary to the State Government and at the federal level became the Chairman Senate Committee on health, all through which he continued to displayed his passion for quality and affordable healthcare for all through enhancing the Primary Healthcare (PHC) service capacity in Delta state and a steadfast contribution towards ensuring the National Health Act and the NHIS Law became formidable through the National Assembly.

As Governor of Delta State, he ensured the bill to establish the Delta State Contributory Health Commission was ready and sent to the Delta State House of Assembly within a few months into his administration.

The bill went through all parliamentary protocols and procedures before being passed and signed into Law with a strong governance structure and processes on the 4th February 2016.

Implementation of the Scheme commenced on the 1st of January 2017 after start-off mechanisms had been put in place despite the start-off financial challenges due to the sharp drop in the State revenue from the falling oil price and inherited debts.

Is this growth sustainable?

Renovation work is ongoing at other healthcare facilities across the State to increase the number of Healthcare facilities available for the scheme with commensurate infrastructure upgrade to ensure quality of service.

Human Resource for Health (HRH) capacity development is also ongoing with behaviour modification training to realign and encourage the ‘Patient First’ attitude amongst healthcare service providers.

Several monitoring and evaluation teams has been commissioned to access quality of healthcare services and compliance with provisions of the Scheme at various levels and to continuously track progress that will enable interventions when challenges or shortcomings are noticed in the Schemes implementation.

Have you been able to share the Commission’s successes to other states planning to commence health insurance?

Due to the success so far achieved and robust nature of the scheme, several States in Nigerian have sent emissaries to Delta State, sponsored by United Nations Children Fund (UNICEF) to understudy the Governance and operating dynamics of the Delta State Scheme with a view to adopting it for their own states.

I have over the past few years consulted and supported the settling up of the Health Insurance programme in several States and the Governor of Delta State, His Excellency Senator Dr. Ifeanyi Okowa, has been a strong advocate for other States to adopt Health Insurance programme at the Governors Forum.

What have been the challenges?

Despite the successes above within such a short period, there will obviously be shortcoming in the Schemes implementation, being a new programme without a clear template anywhere in the country to learn from.

However efforts have always been put in to correct shortcomings through strategic interactions and engagements, which other States in Nigeria are currently learning from for the implementation of their own programme.

The commission is quietly fulfilling its role within the healthcare landscape in line with its mandate and governance structure, saving lives and removing people from the poverty partway associated with “Out of Pocket” payment for healthcare services through a globally accepted healthcare financing mechanism supported by the United Nations and a component of the Sustainable Development Goals (SDGs) to be achieved in year 2020.

Anyone with practical ideas to make the programme work better should be encouraged.

Anyone with criticisms should be allowed to speak and critique under an atmosphere of facts and decency.

I expect the Commission to continue in its efforts undistracted towards achieving quality “Health for all Deltans” and on the long term contribute to achieving “Universal Health Coverage” in Nigeria in line with the United Nations SDG Goals.1

Was this influenced by the large kick off grant you got, which is rumored to be around N350m?

The Scheme did not receive N350 million as Take-off Grant.

The Take-off Grant released to the Scheme in 2016 was N35 million only for its entire year operations.

Delta State at that time received one of its lowest revenue.

With this situation in mind, we commenced a modest start-off processes to enable value maximization of the funds, not compromising significantly on quality of service.

First instead of an elaborate recruitment process, civil service workers already on the State payroll were trained and deployed to the Commission.

Instead of starting off with brand new vehicles, broken down vehicles within the Government house were refurbished for the Commissions use and a section of the State Head of Service office building was allocated as start-off office for the Scheme.

We also worked round the clock to ensure we met expected target deliverables.

Is the scheme building on what the past administration of Dr. Emmanuel Uduaghan put on ground?

The past administration of Dr. Uduaghan, implemented the free maternal and under five years healthcare programme, which improved the maternal and infant mortality healthcare indices in Delta state.

However there were challenges in its implementation with the programme available only in urban centre secondary healthcare facilities and no comprehensive data for tracking, reporting, analysis and long term sustainability plan.

The DSHCS, thus commenced its service by transitioning the previous administration free maternal and under five years healthcare programme into the Scheme to ensure continuity and long term sustainability. It expanded to programme to 107 Primary Healthcare Centres (PHCs) in rural communities where the people that actually need the free healthcare service reside and established a database system that enables all pregnant women and children under five years to be automatically enrolled into the Scheme whenever they visit the healthcare facilities for service free of charge and the healthcare services paid for by the Delta State Government direct to the healthcare facilities. With this strategy, they are able to receive all healthcare services available under the Scheme and have access to healthcare service referrals for higher levels of care with an identity card and patient’s case file for proper documentation of healthcare services provided, ensuring continuity of care with proper medical records.
The scheme seem to have a deep pocket for its running. Are there contingency amounts and other funds pumped into making it work?

There has never been a contingency fund approval for the commission since the scheme began. The Scheme operates a prudent financial management system to ensure that the bulk of funds received are channeled to payment for healthcare services provided to enrollees. Expenditures for the Scheme are approved and expended in line with due process expectations as stated in the Law establishing the Commission. The Governor and the Governing Board of the Commission with budget breakdowns approve expenditure budgets. Also N90 million was never approved for advocacy for the Scheme as erroneously reported in some social media platforms. Instead, N90 million was approved for the Commission’s entire 2017 operations budget with N18 million only approved for advocacy activities across the 25 LGAs in the State that included Townhall meetings, publications, media campaigns, sensitization meetings with all Trade Association/Unions and heads of the various communities in Delta State to ensure inclusion for all segments of the society, amongst others.

How many people are currently under the scheme?
The Scheme currently has over 300,000 residents of Delta State that include pregnant women, children under five years, public service workers and the informal sector. The number changes daily as there are several registration points that feed to the central database daily. The Commission has also commenced a community based registration programme in partnership with the President Generals and secretaries of the various community Town Unions with the kings and traditional rulers made the Scheme’s ambassadors in their various kingdoms and domains.

Health insurance is supposed to ensure universal coverage. What are you doing get more residents benefit from the Scheme?
The Delta State Scheme is in partnership with Interswitch for its Information Communication Technology (ICT) deployment to provide an elaborate online real-time electronic payment systems as well as an identity and health insurance management solution that will ensure payment of premium for the Scheme through several options that include Quickteller, POS, ATM, Cash at bank, and Webpay as well as the quick and real time payment to healthcare providers for verified services to enrollees of the Scheme. The Scheme also has a Self-Registration App on Google Play Store (DSCHC) to enable residents of Delta State register themselves remotely, choose an accredited healthcare facility, transmit data electronically and Pay their Premium online. When the Commission receives the enrollee data and confirms payment, the enrollee’s identity card is printed and dispatched to his stated address via courier service.

What type of services are the enrollees getting?
The DSCHS is focused mainly on preventive and curative healthcare services derived from the baseline assessment survey carried out at the beginning of the programme. The baseline assessment survey was done to determine key household demography, health seeking behaviour, coverage needs and willingness to pay, health facility availability and capacity, health facility readiness to deliver services and a poverty mapping that will identify areas and category of people that would have challenges with ability to pay premiums to ensure no one is left behind.

The service benefits for enrollees are contained in a benefit package document which is a part of the operational guideline for the Scheme available at the Commissions website www.dschc.org.ng. The website also has the Law establishing the Commission, key points about the Scheme, update on the Scheme activities and contact details to reach the Scheme for enquiries and clarifications amongst others.

Before this administration winds down, how much more do you want the scheme to grow?
The primary goal of the Scheme is to have a healthcare service financing system that ensures that any resident of Delta State irrespective of his or her socioeconomic status or geographical location, is able to visit a healthcare facility when he or she needs healthcare services, receive quality healthcare service and departs feeling satisfied with the care provided without any financial strain as a result of the care received.

Thus we aim at registering a significant number of Delta State residents into the Scheme particularly in rural communities currently challenged with access to quality healthcare services, support infrastructure and service capacity upgrade of more healthcare facilities across the State under a strong Governance and Management System that ensure due process, accountability and sustainability of the Scheme.

Before you took over as the Director General of the scheme, what were you into?
Interestingly, the Governor in his wisdom did not make political appointments into the Commission, rather he opted for healthcare financing experts and medical experts with public and private healthcare service experience to regulate and implement the Scheme.

In 2013, while studying at the Harvard Business School in Boston United States (U.S.), I was the only African in the Class. In one of the seminar sessions, each person was to make a presentation on the healthcare service status of his country. I was told to go to Rwanda to get materials for my presentation, as I was not likely to get good materials for my seminar work on healthcare service advancements from Nigeria. Instead I travelled back to Nigeria and went to see Senator Dr. Ifeanyi Okowa who was then the Chairman Senate Committee on Health. I explained my mission to him and he handed to me the draft Bill for the National Health Insurance and the National health Act bill to read in his living room. I read through it, got excited about the prospects and went back to Boston to present the Future of Healthcare Service in Nigeria under a Health Insurance Programme and the National Health Act. I did not bother going to Rwanda. In 2015 when I was again at the Harvard Business School in Boston for another course, I presented the Delta State Contributory Health Scheme programme and received technical advisory support from the Harvard Business Review Team.

When Senator Dr. Ifeanyi Okowa commenced his campaign for Governor of Delta State, I travelled with him throughout the campaign providing emergency medical cover for his campaign convoy which usually had over 40 vehicles and along with other members of the Campaign Medical Committee, started drafting the healthcare policies and priorities of the expected new administration. I was also a member of the Governor-elect Transition Committee on Health and Member/Secretary of the Governors Team that midwifed the Contributory Health Insurance program. When the Bill establishing the Commission was signed into Law, I was appointed the Director General/CEO of the Delta State Contributory Commission.

I obtained my MBBS degree from the University of Benin and a Masters in Public Health from the University of Nigeria Nsukka. I have attended several postgraduate courses that include Occupational Medicine at the University of Manchester in United Kingdom (UK) and Occupational Safety and Health Course for Senior Management at the British Safety Council in UK.

I attended the Managing Healthcare Delivery Programme at the Harvard Business School in Boston USA, the Business Innovation in Global Healthcare Delivery Programme also at the Harvard Business School in Boston USA, a Health Economics course at the London School of Economics UK and obtained two Project Management certificates from the Oxford University UK.

Before my appointment as the DG/CEO of DSCHC, I was the Managing Director a Healthcare Consultancy organization and the Chairman Board of Directors of an Oil and Gas Service company.

I was the Pioneer Medical Director of Delta Specialist Hospital in Bonny Island and one of the Pioneer Medical Doctors at the Nigeria Liquified Natural Gas (NLNG) project Hospital in Bonny Island in Rivers State.

I was also the Medical Officer for a number of International companies that built the Trains 1,2,3,4 and 5 NLNG plant in Bonny Island example The TSKJ Consortium Site Clinic, Meisie Industrial Company Japan Site Clinic, Japanese Gas Corporation Site Clinic, Deawoo Site Clinic, Italian Cimimontubi Site Clinic amongst others, all at the NLNG project site in Bonny Island.

Before setting up the Delta Specialist Hospital and my service at the NLNG Project Clinics in Bonny Island, I was a Field Medical Officer for Schlumberger Oil Service Company where I provided healthcare service to both the company workers and the rural community residents across the Niger Delta region and thus developed the interest and passion for rural healthcare services, incidentally in line with my Principal Senator Dr. Ifeanyi Okowa the current Governor of Delta State.


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