A PAPER PRESENTED
@
THE NATIONAL SCIENTIFIC CONFERENCE
OF THE ASSOCIATION OF MEDICAL OFFICERS OF HEALTH IN NIGERIA (AMOHN)
By
DR. JIDE IDRIS
Commissioner for Health, Lagos State
OUTLINE
 Challenges of healthcare
 Strategies to improve Healthcare Financing
 Specific Challenges of Primary Health Care
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(PHC)
Strategies for revitalisation of PHC
Universal Health Coverage
Health Insurance as a sustainable Healthcare
Financing Strategy
General Overview of CBHIS
CBHIS in Lagos State
Current Challenges of Healthcare
 Population- ability to mobilize enough money to
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meet desired expenditure
Disease Burden
Economic structure – huge informal sector
Budgetary Allocation and demand from other MDAs
High Out-of-Pocket system
The private facilities provide healthcare for over
55% of the population in the State.
Quality Issues
Human Resource Challenges
Strategies to improve
Financing of PHC
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Free Health Scheme
PPP
Revamping the Tax System
Increased Budgetary allocation to Health
Exploring ways and means of increasing efficiency of
the system
Health Insurance (CBHI – pilot schemes): To replace out
of pocket expenditure on health.
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TOTAL PERCENTAGE ALLOCATION OF BUDGET TO THE HEALTH
SECTOR, 2004 -2013
9.00
8.00
7.87
7.67
7.53
6.00
5.81
5.65
in percentage
7.08
7.01
7.00
5.36
5.3
5.00
4.00
% ALLOCATION ( TOTAL)
3.28
3.00
2.00
1.00
0.00
Y2004
Y2005
Y2006
Y2007
Y2008
Y2009
Y2010
Y2011
Y2012
Y2013
Specific challenges of PHC
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Poor Coordination and Low Level of Community
Participation in PHC.
Dilapidated Infrastructure:
Inadequate number of staff.
Inadequate staff capacity.
Poor Staff Attitude (Service-Provider Misconduct).
Irregular supply of Essential Drugs and other
commodities
Unsustainable Financing.
Universal Health Coverage (UHC)
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Definition: WHO defines UHC as access to key promotive,
preventive, curative and rehabilitative health services of
good quality for all at an affordable cost.
Goal: The goal of universal health coverage is to ensure that
all people obtain the health services they need without
suffering financial hardship when paying for them.
WHA Resolution 2011 asked: Member States to develop
their Health Financing system towards universal coverage.
Primary health care is crucial to attainment of UHC
UHC: Concept
Universal coverage:
 Lays emphasis on equity.
 Is a critical component of sustainable development
and poverty reduction.
 Is a key element of any effort to reduce social
inequities.
 Is the hallmark of a government’s commitment
UHC: Factors Responsible for Catastrophic
Health Care
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Exclusion linked to Social Determinants or Factors outside
of Health System: inequalities in income, level of education,
Gender, Migrant Status etc.
Weak Health System: Insufficient health workers, irregular
supply of life saving commodities and drugs, inadequate
health technologies, ineffective service delivery, poor
information system and weak government leadership.
Non-functional and unsustainable Health Financing
System. The other building blocks of the health system
cannot function if the financing system is weak.
UH: Component
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Access to care.
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Quality of care.
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Sustainable financing (reduction of out of pocket
expenditure on health)
Health Insurance as a Sustainable
Healthcare Financing Strategy
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Health risks are usually insurable, in that health crisis
occur to individuals mostly independent.
In health insurance there is usually interval between
time of payment and time of use of health care
services This makes it possible demand for health care
services by members who ordinarily could not afford
the real cost of services.
The poor benefits from health insurance in that they
usually bear high indirect costs of treatment due to
their limited ability to mitigate risk.
Types of Health Insurance
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Social Insurance: Provision of insurance with some social
considerations.
There are two types of Social Health Insurance:
Mandatory Health Insurance Scheme: For the Formal Sector
(NHIS).
Community Based Health Insurance Scheme: For the informal
sector.
Market Insurance: Provision of insurance with purely
commercial consideration. The price of market insurance is
usually beyond the reach of low income earners.
Concept of Community Based Health Insurance
Scheme (CBHIS).
CBHIS
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A micro finance scheme for healthcare delivery
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Designed mainly for covering health risks.
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Its emergence is as a result of the crisis in delivery of healthcare to
the low income people and the success of community based microcredit schemes
Is a form of decentralization process too empower local communities
fulfill their health care needs.
CBHIS is based on the realization that that even the poor can make
small, periodic contributions that can go towards meeting their health
care needs.
Concept of CBHIS contd.
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A tool in financing healthcare provision in low income
environments.
Provides income protection measures
Designed to improve access to healthcare through risk
pooling and resource sharing.
The concept is more applicable and work for informal
sector
Needs to be piloted before scale-up
Strengthens demand side and thereby helps the poor
to articulate their own healthcare needs.
Concept of CBHIS contd.
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Better positioned to organize the provision of health services which is
pre-condition for generating demand for health insurance.
Incorporates both financing and provision aspects of healthcare
delivery.
Better positioned to harness information, monitor behaviour and enforce
compliance among members.
Has lower transaction costs than market or mandatory insurance because
it is managed by local organizations
Attracts higher membership because it community based and therefore
enjoy the support and trust of the local people.
Depends on local incentives and enforcement structure.
Features of CBHIS
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Voluntary participation of the people
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Not for profit
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Managed by the community
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Risk pooling and cost sharing.
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May collapse in the presence of covariate or
aggregate risks.
Factors that may constraint enrollment
into CBHIS
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Income
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Religion
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Ethnicity
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Quality of care
Benefits of CBHIS
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Offers financial protection for low income earners.
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Mobilize resources through members contributions.
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Eliminates of social exclusion
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Promotes organisation and provision of health care
services according to the need of the community.
Challenges of CBHIS
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Setting Incentives : How to set incentives for scheme
managers to expand risk pool and better manage CBHIS
in low income settings is a major challenge
Adverse selection problem: Usually mitigated by defining
households as units of insurance as opposed to use of
individuals.
Moral hazard problem: Increasing individual health risk
after enrolling due reduced care of health after joining or
over consumption of medical services. Usually mitigated
through group insurance contract.
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Majority of CBHIS depend on external funding for
sustainability.
The poorest people could not afford to enroll may
still not be covered.
The reach of CBHIS is limited due to small number
of schemes and small membership. However this
could be improved upon.
Challenges of CBHIS contd.
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CBHIS may collapse if too many people turn out to
require healthcare services.
Individuals have no options. Its either you enroll or you
don’t.
Development and design of a scheme with regards to
timing and periodicity of payment is crucial to the
success of CBHIS
Schemes that allow both households and individuals as
unit of insurance tilt membership in favour of household
by giving discount.
CBHIS – Rationale
 Collaboration between governments (State and
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LGA)
Address HRH issues
Private sector resource
PHC challenges / address issue of access
Address the informal sector / poor and
vulnerables
Prepayment mechanism
Community Engagement / Involvement
Element of economic empowerment and enterprise
promotion
Element of Risk Sharing
Lagos State (LS) CBHIS: Options
 Option 1
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The Government provides the Primary Health Care (PHC) facility and
equip, interested private provider to staff and manage the facility.
 Option 1a
The Government provides the Primary Health Care (PHC) facility,
interested private provider to equip, staff and manage the facility.
 Option 2
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The Government would make use of the private practitioner’s facility,
staff and equipment.
 The Ikosi-Isheri and Ibeju-Lekki LGA and CDA selected Option 1 for
implementation
LS CBHIS: Component
 State Government – Payment of subsidies, capacity building and
Technical support, M & E, mobilization support and facility development
 Local Government – facility development and maintenance, payment of
premiums for selected/needy community members
 Community members – premium contribution and ownership / BOT
 Private sector – staffing, equipping and service provision
 Economic Empowerment (Skill acquisition) / Enterprise promotion through
WAPA and microfinance institutions
 Referrals
LS CBHIS: Data Management
 A software developed for the scheme that is accessed
at 3 levels: Administrator (SMOH), Facility (Provider)
and MHA.
 The MHA provides data on: enrollees, premiums paid.
 The Provider provides data on clinic utilization,
diagnoses, referrals.
 Data is collated and analyzed at SMOH level with
monthly reports produced which serve as a monitoring
tool.
LS CBHIS: Payment Structure
 Payment of the initial fee confers membership on the
enrolling family or individual.
 Family Identification /membership card are provided
with photographs of the principal enrollee and names
of all other dependants to deter abuse of services.
 The monthly fee (premium) is to be prepaid for each
month by the 28th of the preceding month with a
grace period extending into the 7th of the new month.
 Payment after this period attracts a 10% surcharge
after which services will be suspended for the
defaulting member until the payment is effected.
 Provider payment is by capitation
 Subsidy paid by government
LS CBHIS: Benefits Package
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Treatment of common ailments
Antenatal care
Family planning.
Immunization.
Management of uncomplicated (normal) deliveries.
Referral to secondary care centre.
Health education
Provision of other services under the free health scheme
of government e.g malaria and TB.
 Skill acquisitions training by WAPA.
 Provision of soft loans for those with identified trade.
LS CBHIS Pilot: The Ikosi-Isheri Scheme
 Began operations at the Olowora Primary Health Centre
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in July 2008.
Scheme is targeted at the peri-urban Olowora, Magodo
and Isheri communities, with an estimated population
of 70,000 persons.
Premium is set at #1200.00 per month (initially N800)
for a family of six and N600.00 per month for individual
enrollees.
#300 per month is paid for any additional member
exceeding accepted family unit of six.
The scheme offers primary healthcare services to all
enrolled members of the community.
The scheme is in its sixth year of operation and has
enrolled 18,092 people since inception at one time or
the other.
Total Enrollee Population/Year
5000
4705
4500
4144
4000
3297
3500
3000
2500
2482
2000
1500
1000
500
0
2009
2010
2011
2012
Cumulative Enrolee Population
Scheme Service Access Pattern
Morbidity Profile of patient Encounters
Families with ANC Users
Premium Subsidy Profile
The Ibeju-Lekki Scheme
 Commenced operation on the 1st February, 2011
 Located at two Public facilities Awoyaya and
Iberekodo Health Centres
 Premium is set at N 1,200 less subsidization.
 Capitation for provider is set at N1,500/ family of six
 Higher number of subsidized families (1,150 versus
500 in Ikosi Isheri)
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Instead of reimbursing 100%, reimburse 50%
 Low operational processes requiring training for Ikosi
Isheri MHA staff
Ajeromi Scheme
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Scheme commenced operations in January of this
year Tolu PHC.
 The scheme is managed by a 7-member Board of
Trustees of the Mutual Health Association (MHA)
for Ikosi-Isheri.
 Premium is N1,200 for a family of six , N300 for
any additional member and N600 for individuals.
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Currently there are total of 2157 enrollees
LS CBHIS: Studies
 Actuarial Analysis of Ikosi-Isheri Scheme
 Actuarial studies conducted to ascertain ideal
premium and subsidy level for scale-up and for
maternal and child care in 2012.
 Participatory
Wealth
Ranking
exercise
conducted in Ibeju-Lekki selected communities to
identify the poor.
LS CBHIS: Challenges
 Rise in attrition rates
 Poor Data Management
 Poor support from LCDA Leadership
 Inadequate M & E
 Pro-poor component yet to be incorporated
Lessons Learned
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A latent period is requisite to build up numbers for
scheme viability.
Attainment of optimal population requires Initial
Intense Mobilization while sustenance and increase
in population requires continuous mobilization
strategies.
Quality of Care is a powerful tool in sustaining
continuous enrolment through word-of-mouth adverts
Scheme uptake is geographically determined by
proximity of a target community to MHA
office/information center/healthcare provider
Lessons Learned
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Infrastructure and processes necessary for the
proper enforcement of risk management rules
must be implemented before launch of scheme
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Committed leadership is key success factor for
the scheme (both LCDA and BOT leadership).
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Feedback from community is essential to
scheme success.
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Setting subsidy level targets encourages more
determined participation by BOT.
Moving Forward
 Outsourcing of data management
 Increase information sharing with members through
more regular meetings and sensitization in all
communities- stakeholders meeting now quarterly
rather than yearly
 Consider loyalty plans to encourage low utilizers to
stay in the plan.
 Consider alternative premium structures to increase
persistency.
 Commence means testing for selecting deserving
families for health plan subsidies.
Moving Forward
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Consider budget limits and subsidy targets going forward.
 Need for innovative methods of facilitating sustained premium
renewal
 Consider alternative community and individual outreach
approaches- employment of community youths to conduct daily
marketing of insurance with targets is being explored by the
BOT.
 Consider bringing on board HMOs to stimulate MHOs and the
development and growth of CBHIS at the grassroot.
 A blueprint is being developed to scale up the CBHIS to all the
LGAs/LCDAs with the incorporation of the Maternal and Child
Health Reduction Programme.
Conclusion
CBHIS is not just a viable
option, but the most
sustainable mechanism for
financing of PHC.
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