Integrating financing mechanisms to achieve universal health coverage

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Permanent Secretary, Federal Ministry of Health (FMoH), Abdullahi Mashi Abdulaziz (left); Deputy Governor of Delta State, Barrister Kingsley Otuaro; Technical Director, Basic Health Care Provision Fund (BHCPF), Dr. Oyebanji Filani; Chairman Oshimili North Local Government Area (LGA) of Delta State, Louis Ndukwe; Director-General, Delta State Contributory Health Commission (DSCHC), Dr. Ben Nkechika; and Chairman, DSCHC, Dr. Isaac Akpoveta, at the take-off of the BHCPF programme at Akwukwu-Igbo Primary Health Care (PHC) centre in Oshimili North LGA

The quest for Universal Health Coverage (UHC) has led to the introduction of several financing mechanisms.

Until now, the World Health Organisation (WHO) recommends the use of a pre-paid mechanism that will ensure that the patient does not pay for care out-of-pocket. This method, which is used by several health insurance concepts ensures that the subscriber pays a yearly premium that covers a range of diseases and medical diagnoses.

This is the method adopted by the National Health Insurance Scheme (NHIS) where an individual will pay a premium that will cover him or her, the spouse and four children.

For instance, in the Delta State Contributory Health Scheme (DSCHS) run by the Delta State Contributory Health Commission (DSCHC), the individual pays a premium of N7,000 yearly, which covers the treatment and diagnosis for malaria, typhoid, diabetes, hypertension, maternal and childcare issues including delivery through Caesarean Section (CS) and immunization, surgeries, psychiatry, and blood transfusion.

Unfortunately, there has been a slow uptake of the health insurance programmes both at the national and state levels because most of the programmes are not mandatory and are structured to cater to the formal sector.

But the introduction of the Basic Health Care Provision Fund (BHCPF) by the Federal Government (FG) is changing the narrative. The BHCPF was made possible by the National Health Act (NHA) 2014. The law, which was passed by the 7th Senate led by David Mark as President and Dr. Ifeanyi Okowa as the chairman Senate Committee on Health mandates the FG to set aside at least one per cent of the Consolidated Revenue (CR) for basic health care needs especially at the Primary Health Care (PHC) levels.

The 8th Senate led by Dr Olusola Saraki, with President Muhammadu Buhari’s approval, provided N55.1 billion in the 2018 budget for the BHCPF. This health package is to take care of the normal reproductive, maternal, newborn, child, adolescent and nutrition health, the screening of non-communicable diseases and emergency services.

However, critics are worried that the BHCPF promises free treatment for 70 per cent of diseases covered by the states’ health insurance schemes. They said this would discourage people from buying a health insurance package since basic health care services are offered free-of-charge by the BHCPF.

Benefits

What are the benefits of health insurance? Chairman DSCHC, Dr Isaac Akoveta said: “It is a concept generally you paying a little money upfront for a little contingency in your life so that when that problem occurs you do not have to look for money at that moment because you may not have the money at that point.

“For example, you have an accident with your car and you have no insurance, you have to go and look for money to repair the car or to buy new care. But if you have paid a premium with insurance, the insurance company will just come because they pooled money from all sort of customers to be able to repair the vehicle for you without stress.

Health insurance is similar, you contribute some little money or the government contributes for you based on who you are and when you are sick you do not have to check your pocket, you just take your card and walk into a centre and receive treatment.”

Akpoveta said one of the major things that anybody would benefit in this scheme is ensuring that he or she does not suffer financial distress on the point of care when they need care. He said with BHCPF of the FG, you do not have to pay because there are some people they will pay for.

Akpoveta explained: “If they pay for you, they will just give you a card and you just walk into a centre and receive treatment. For example, Delta State Health Insurance Scheme is currently paying for all pregnant women in Delta state. Just get your wife pregnant and leave it to us and we will take it over from there until she delivers. If she cannot deliver by herself she will also be operated free of charge.”

The medical doctor said although there is no free food in Freetown, the government is paying for it and the DSCHC pays millions probably billions now for pregnant women and as soon as that baby is delivered, from the day he or she is delivered until the child is five years; it is the responsibility of the Delta state government to pay for whatever ill health that child will suffer.

“So you can see it is a beautiful thing. Then it is also meant for those who have physical deformities; challenges and they pay for them. It is also going to be extended to people 65 years and above, and who cannot pay, they will be paid for,” he said.

The DSCHC Chairman said by the time the funds come, this group of people, more of them will be taken in and they will receive treatment that is free. “You receive malaria treatment free, typhoid is free, generally all the basic illness you receive free treatment. Also for some basic surgeries like hernia, caesarean section all those ones are free. However, if you want to do kidney transplant or orthopaedic major surgeries, we cannot handle those ones now but minor surgeries we can handle now. So we can handle about 80 per cent of health needs of Deltans and off Nigerians,” he said.

Flag off of BHCPF

Permanent Secretary, Federal Ministry of Health (FMoH), Dr Abdullahi Mashi Abdulazeez, told The Guardian: “I think the first rollout was done in Osun. Three states have already flagged off. Delta is joining as the fourth state now. NHIS is more of a formal sector and more of federal government staff. But BHCPF is more of at the PHC level. We are now trying to reach the preponderant of the underserved. We want to turn the pyramid. We want to come back to a situation whereby Nigerians we will be able to access medical services at the PHC level. That is the essence.”

Abdullahi said the first tranche of N13.75 billion, that is a quarter of the one per cent, has been distributed and Delta has got N700 million which will be shared 50 per cent to the DSCHC and the 45 per cent to the PHC.

Governor of Delta State, Dr Ifeanyi Okowa, told journalists and a team from the FMoH led by the Permanent Secretary: “I want to appreciate Mr President for also enabling the launch of the programme and now we are trying to scale it up in such a way that it gradually gets to every state. I also want to use this opportunity to advise my colleagues to be able to provide the needed counterpart funding as much as possible.

“It is important that we try and provide money for PHC delivery because once we are able to take care of PHC services for our people we will lessen the number of Nigerians wishing to travel overseas, we will also lessen the number of Nigerians seeking for secondary and tertiary health care. Nowadays a Nigerian has malaria and he or she will want to go abroad for medical treatment. It is becoming so unfortunate.”

Using BHCPF to scale up health insurance programmes

Okowa said he hopes that the FG will strongly drive the process that will enable them to upscale the number of Nigerians that have access to health insurance.

The Governor explained: “Going forward we will begin to see early signs of the benefits. Luckily for us through our advocacy programme, the civil servants have become enrolled and they are impressed by it and it is something we are happy with. But there is still a lot of work to be done by us but I believe that this is something that we must drive through many of the states because until we take this advocacy to the states individually it will be scary.

Many people feel scared to step into this process because the BHCPF will not be able to do all the work unless we are able to throw in, partner with the FG on this by providing adequate resource support for the growth of the health insurance policy.

“ I am very convinced that it will take some time but with time I believe that we will have better PHC facilities that will attend to our people. We actually took time to restructure the breakdown of funds to make sure that no part of PHC is actually left out and hope that the resources will be used appropriately at the various levels. For me, it is a thing of great joy to see this actually being implemented. It gives us a success story, the reason to feel fulfilled that this has come to be.”

The former chairman Senate Committee on health said he hopes that the funding and the support coming will help the DSCHC reach out to the various more vulnerable group and will be able to attain the mark. Okowa said they have set a target for themselves to be able to cross the one million mark before 2023. “We are hoping that we will be able to do that. I think it is not impossible, we only need to work hard as much as we can,” he said.

Ensuring accountability

Okowa said the National Primary Health Care Development Agency (NPHCDA) has a lot of work to do in terms of monitoring and hopes that they will stand strong to monitor and ensure that funds are appropriately used because the health of the people is so important.

He added: “Because we are talking a lot about poverty and unemployment, I believe that if we are able to provide these services to the vulnerable, we would have been able to save people a lot of expenditure from their pocket and beyond that they will also have access to better services at very close locations.”

Abdulahi said the FMoH has a checklist and each state is supposed to follow up with a counterpart fund of N100 million, which is supposed to be domiciled at the ministry of health of the particular state and that is supposed to take care of the state PHC development agency for their logistics.

The Permanent Secretary said the FMoH has very formidable monitoring and evaluation mechanism. “At the national level we have a national steering committee, which will also be replicated at the state and local government levels,” he said.

Technical Director of BHCPF, Dr. Oyebanji Filani, said the other important point to make is that it is one thing to send the money and have internal mechanisms to make sure that it is appropriately utilised and it is another thing to set up independent verification that would also provide independently an assessment of how the funds are being used. He said they are engaging with the ministry of finance very closely so that they can get those who will begin to do that.

“We are constantly with the CSOs who have come up with different kinds of trackers and scorecards to examine and determine how the funds are being used. All of these are going at the backend just to make sure that now that we have pushed the money to the states and states will push to the facilities, all is in gear,” Filani said.

Fears of a clash between BHCPF and states health insurance programmes

Akpoveta said the BHCPF is complimentary to the DSCHS and gave assurance that the two programmes are not going to clash. “It is going to compliment us. It is going to give us more funds and make us register more enrollees,’ Akpoveta said.

Abdulahi said: “I don’t think there is any clash. It is more of collaboration. It is more complimentary. Mind you, health is on the concurrent list of our constitution. So the FG has a role to play, the state government has a role to play even local governments.

“The DSCHC is more of addressing the formal sector at the state level but the BHCPF is addressing health care needs minimally at the ward level. We want a situation where every political ward will be able to have at least one functional PHC centre whereby the underserved will be able to access basic health care facilities.”

The Permanent Secretary added: “As I said, we want to come back to the basics. Health care should start at primary. It is when the facility cannot address the issues that you make a referral to the secondary and tertiary. Unlike the current situation where somebody has the flu will go to a tertiary centre, we want a turnaround and that is the essence of the BHCPF.

“The NHIS will still continue the role it is playing now. Like I said NHIS is more of the formal sector as of now. It is more of an urban thing. Look at the situation we have in this village, do you think you have any functional federal facility here? So the essence of the BHCPF is to reach the underserved, the vulnerable.”

The technical director of BHCPF said there is no clash with NHIS at the state level. Filani explained: “I say no because there can be complementarity between what exists at the state level and what the FG is bringing to bear. The first and foremost if you look at the benefits package of the BHCPF and the benefits package under the state health contributory schemes, almost 80 per cent that is in their scheme is already existing in the BHCPF. So if we were to look at it in bundles, you will consider the BHCPF as the base bundle and you could have top-up bundles.”

Filani said Delta is extremely interested in working together with them and they have written to the BHCPF requesting for a technical report to align their insurance package with the BHCPF. “We will be all over them within the next one or two months just to ensure that this is done. The goal is to ensure that you can have separate packages but the goal is to ensure that it is seamless. So we will do that with Delta and as many states who will demonstrate interest, we will definitely support them. But I think we have a good base in Delta,” he said.

Challenges

Akpoveta said Delta will meet the target of one million enrollees much earlier probably by the end of 2020 but are constrained by limited resources in most of the facilities. He, however, said the government is making efforts to ensure that the facilities are upgraded in terms of all the resources, equipment, personnel, and the structures themselves.

Akpoveta further explained: “All these are being galvanised and upgraded and so we can ensure that you will pay your money or you are paid for and you get to facilities and you receive good quality care in a decent environment. So to achieve that decent environment is a constraint but we are working on it very well and His Excellency is very interested in ensuring that is done.”

Filani said the major challenge with the BHCPF is making sure that they are able to appropriately support the states to move forward.

He explained: “As I mentioned earlier, we have 28 plus one states, the one being the Federal Capital Territory (FCT) who have demonstrated willingness. At the federal, we are putting together batches of a team who will support the states in training them. It is not enough that we release the money, we have to ensure that the capacity is built and we also have to strengthen the accountability process within the mechanism in a manner that once the funds are released, people are able to utilise them for the ultimate good.”

Director-General of DSCHC, Dr Ben Nkechika, said the major issue that they have encountered is that there is no clarity on the inclusion criteria for the BHCPF. He said it was first expected to be a fund that is an offshoot of the National Health Act to implement the PHC gateway and the health insurance gateway across all the states.

Nkechika explained: “We now heard that it was supposed to be a pilot and we felt that if it was going to be a pilot Delta state already had a structure on ground to implement a pilot than start a pilot from nothing because the pilot is a test of concept. It was explained to us that Delta could not be in the first and later there were more and more states but eventually we were included. What we felt was to actually showcase the governor’s passion, which he championed in the National Assembly to ensure the passage of the National Health Act and the NHIS that the political will to implement and showcase the BHCPF should start from the state that has that political willingness and capacity and that is what we have been pushing and that is what we have achieved today.

“Now what problems have we had? The first problem is the fact that at the national level the minimal communication that has come down to the state on the BHCF is a big challenge. I give you an instance, a lot of states have the assumption that the BHCPF is either a parallel health programme to the NHIS or a programme designed to shut down the NHIS because one person situated it to a very simple analysis- you are telling a state to set up a health insurance programme to sell a basic health care package at least say N5,000, N6,000 and N10,000 and it is being run by the state and the state is putting all its resources to implement it.

FG brings resources to offer part of those services free of charge. So it is like telling somebody that there is 30cl Coca Cola for N1,000 and 20cl Coca Cola is free. Nobody will buy the 30cl Coca Cola because they will just go for the free one and that will kill the health insurance programme. For my understanding that is not what the BHCPF is all about, that is not even in the manual.”

“So you have a manual that was launched by the President and you are seeing an implementation that you do not even understand. Like I will give a typical example, every state was told to provide a counterpart funding of N100 million but because of lack of information from the federal level some states say the N100 million is for the PHC, some states say it is for the ministry of health. So there is so much confusion. So where there is confusion, implementation is stalled.”

Free health programmes and sustainability

Nkechika said: “First of all we do not believe there should be anything like a free health care programme. Instead what we believe is that you set up a health care programme that has a financial sustainability plan. Those that cannot afford to pay you pay for them; you don’t call it free anymore. Those that can pay will pay and that that cannot pay somebody pays for him or her. So it is that ability to keep paying for the people that are sustainability plan. Let me give you an example of what we do in Delta state, there is a free maternal health care programme that was running which we inherited.

“So what we did was instead of calling it a free maternal and health care programme we call it equity health plan in the DSCHC and the government pays their premium.” Integrating BHCPF and DSCHC

Have you harmonized with the FG? Nkechika, said: “Yes and no. Luckily the meeting with the NHIS this evening helped normalise this because I will give you an instant, when we requested and we got information that the BHCPF is going to be implemented, the first letter we got from NHIS was to our governor, telling us to implement a health insurance scheme in Delta state while we have been operating for two years.”

Nkechika further explained: “What we are saying is that there has to be that handshake of a unified system as against a fragmented system that is neither here nor there. So when we got that notification, there was also notification from NPHCDA to the state PHCDA. But the flow from the NHIS part was not very smooth, which was why the acting executive secretary of NHIS was here. That was what we resolved today.”

So it means what the DSCHC is doing is the same as the BHCPF? Nkechika said: “It is the same thing but the only difference is the package. Instead of the DSCHC package that has 10 items, BHCPF has three. So it means one to three is free and four to ten is covered, that is seven items/diseases is covered. So what we are explaining to them is one to three covers at least 70 per cent of the cases you see in the hospital. So if you make the three free people will not be willing to pay the N7,000 because the package from BHCPF is free.

“What we are now saying is this once you register for the BHCPF you automatically register for the DSCHC programme. The only reason we can do that is because we have an existing health insurance programme. So anybody that comes here to receive free health care is automatically registered in the health insurance programme to receive this.

“What we are doing now is because of our technical capacity, the FMOH has not even accepted it. We came up with that proposal to them and we are now discussing.”

Does that mean the BHCPF is a threat to the states health insurance programme? Nkechika explained: “Yes! If you tell somebody to register with DSCHC and pay N7,000 premium he or she will tell you that it is malaria that I usually get and the treatment is free with the BHCPF. But we are going to restructure it and say one to three is basic health care service and four to 10 extra health care package.

Our benefits package covers surgeries, psychiatry, CS, blood transfusion. Our benefit health package is not quite different from NHIS. It is quite elaborate. Cancer and kidney problems are not covered but the investigation is covered. What we are looking at is that our programme is not structured to handle complicated cases but to handle more of prevention and early detection. We believe that if you take care of that the financial requirement to manage heavy cases will be greatly reduced.”

How are you going to integrate it into the BHCPF? Nkechika explained: “That is why we decided that before we start that we must have an ICT because ICT can now differentiate the various packages. We must have an effective Drug Revolving Fund (DRF) system to ensure that drugs revolve around the PHC centres in good quality and at the right prices and that is why we have Sanofi as our partner.

The DRF is a central store where all the drug producers send drugs. We confirm quality and we distribute to the PHCs. They utilize it to provide care and pay DRF for it. The drug is free to the patient but the DSCHC pays for it. So that is why we insisted that the money is paid to the health care facility and the facility pays for the dug it has collected from the DRF.”

Introducing ICT platform to enhance integration

Nkechika said: “When we started our DSCHC programme because of the laborious paperwork requirement we felt we have to be efficient and effective we plan to deploy a complete ICT system. There was an ICT challenge at PHCs so we started with manual and we have gradually transited into the electronic system. We felt that there should be a database of enrollees that you can call up immediately and that was why we developed the electronic medical records.

“We also now have a situation in some PHCs where there are not doctors and nurses and we found out that most of these Community Health Extension Workers (CHEWs) don’t have the requisite skills to provide a certain level of care. So we developed a treatment protocol that is based on the NPHCDA treatment guideline so that even if it is a CHEW that is in the hospital and a patient walks in and says I have a fever, if the CHEW types in the fever it will have a dropbox that will ask more questions. Those questions will guide the CHEW towards a diagnosis. If it comes to the typical diagnoses of malaria the application will also suggest to the person on the type of diagnosis to do to confirm if it is malaria. That gives you a complete encounter data. The person confirms it is malaria the app will help the CHEW with treatment options and the app will also help to cost the treatment. So at the end of the month, it will now tell us how many patients are seen in a month and the kind of diseases they presented and the cost of treating them.

“Because we do not want technology to be a barrier it will run side by side with the manual process. For the proof of concept, we have piloted it in some PHCs and in three secondary health care facilities and it was successful. Two critical challenges are the ICT capacity of the people and poor power supply. For power, we have put solar in all the PHCs so that they can charge the system.

In terms of the ICT capacity, we found that they were just scared of a desktop because we brought in a customized desktop that can actually use solar of regular power supply and it runs on android. So the desktop is like your android phone and all the applications are there. So when we found out that the desktop was so elaborate for them we now put the software in a miniature version in handheld android and the secondary centres now have the desktops.”

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