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DEDICATION

DEDICATION. This lecture is dedicated to: Dr. O. O. Akinkugbe CON,MD,NNOM Professor Emeritus College of Medicine, University of Ibadan for his outstanding contribution to Health Care delivery system in Nigeria including National Health Insurance Scheme. 36. Health Financing Mechanisms.

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DEDICATION

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  1. DEDICATION • This lecture is dedicated to: Dr. O. O. Akinkugbe CON,MD,NNOM Professor Emeritus College of Medicine, University of Ibadan for his outstanding contribution to Health Care delivery system in Nigeria including National Health Insurance Scheme 36

  2. Health Financing Mechanisms HEALTH CARE PROVIDERS Risk Sharing Entity (Prepayment Scheme) 5 Out of PocketGeneral Taxation Social Insurance Private InsuranceInformal Sector Payment Tax Collection Social Health Insurance (NHIS) Private Health Insurance Community Health Insurance (CHIS) HEALTH CARE CONSUMERS 37

  3. WHO Geneva 1999 38

  4. MATERNAL MORTALITY IN SRI LANKA 1940 -1985 Maternal deaths per 100,000 livebirths 39 WHO 99020

  5. Brouwere 2001 40

  6. CAUSES OF MATERNAL DEATHSGLOBAL ESTIMATES WHO Geneva 1999 41

  7. Causes of Death in First Month of Life Lancet 2005 Infections 36% 42

  8. Adverse Consequences of Malaria in Pregnancy Malaria Pregnant Women Parasitemia Spleen Rates Morbidity Fetus Anemia Abortion Fever illness Stillbirths Cerebral malaria Congenital infections Newborn Hypoglycemia Low birth weight Puerperal sepsis Prematurity Mortality IUGR Severe disease Malaria illness Hemorrhage Mortality Effective Interventions • Intermittent Preventive Treatment (IPT) • Insecticide-treated nets (ITNs) • Case Management J. E. YARTEY 2006 43

  9. WORLD HEALTH ORGANISATION2000(RANKING) • NIGERIA-187 OUT OF 191 COUNTRIES. • A NATION IN MOURNING PLANE CRASH:ADC,BELLVIEW,SOSOLISO • PREGNANT WOMEN 150 • CHILDREN 15O EVERY ALTERNATING DAY ADETOKUNBO LUCAS 2OO6 44

  10. Collapsed Building due to Lack of Appropriate Structural Framework 45

  11. UNITED NATIONS DEVELOPMENT PROGRAMME(RANKING)2006 46

  12. HEALTH STATUS TODAY • That the Federal government is implementing comprehensive reforms in the Nigerian Health Sector; • That Nigeria has one of the worst health indices in the world and sadly accounts for 10% of the world maternal deaths in Child Birth whereas she represents 2% of the world, as at year 2000; • That the Nigerian Health System is dysfunctional and grossly under-funded; • That the country lacks an integrated system for disease prevention and management, while key social correlates of ill-health; including poverty, accidents, illiteracy, water and sanitation, good housing, clean environment, gender inequality, unemployment, corruption, collapse of infrastructure and services, are still prevalent; • That the attitude of certain Health Workers reflect their non-accountability to their duties and the funds/equipment committed to their care; • That education and mobilization for mass participation in demanding health rights and other political decisions are inadequate; • That Nigeria is one of the countries in the world that spend very little par capita (9.44 USD) on health; • That road traffic accident and violence have become major health problems; • That the country’s health sector trains and develops human resources, but losses them to other sectors within the country and abroad due to relative higher remuneration, welfare and motivation packages; • That the National Health Management Information is still weak; • That Social Health Insurance Scheme remains one of the most cost effective, efficient, equitable and sustainable way of polling funds for health; and • There is disconnect between research findings, dissemination and utilisation 47

  13. WAY FORWARD • The Federal Government is hereby commended for initiating and implementing health sector reforms; • Efforts should be intensified to improve staffing and facilities at Health Establishments by all tiers of government, through definite political commitment; • Existing health facilities should be equipped and well-managed, rather than build new ones in the same or close locations; • Accessibility of health services should be made fundamental right of every citizen; • Nigerian should increase her per capita spending in health from 9.44 USD to 100 USD • Emphasis must be focused on health promotion and disease prevention in all levels of the society; • Appropriate measures are necessary to reduce vehicular and industrial accidents to the barest minimum, and effectively manage them when they occur; • The National Assembly is implored to pass the National Health Bill without further delay, and definitely before the end of the present administration in May 2007; • The current reforms should be firmed up through the institutionalization of monitoring and evaluation mechanisms for health policies and actions, and the strengthening of National Health Information System; • The National Health Insurance Scheme should expand coverage and reach persons in the rural and urban centres, and formal and informal sectors, while prepayment schemes should be scaled up; • The media should play its constitutional role in holding governments accountable and empower the public and civil society to hold leaders accountable, using established benchmarks; 48

  14. WAY FORWARD Cont. • A special system of social welfare focusing on providing safety nets form the disadvantaged or vulnerable groups in Nigeria should be instituted for the unemployed, aged, the poor, etc through micro-schemes at the community level, including isolated and nomadic communities; • Formal incentives should be provided to promote Not –for-Profit and Community-based Insurance Scheme; • New competitive system of staff remuneration, welfare and compensation package should be evolved for practitioners in both the private and public health sub-sectors; • Institutional framework should be created to feed the products of Research Institutes to the Pharmaceutical Companies and other potential consumer/clients, by inaugurating a committee consisting of all research and product control agencies; • Stakeholders in the Health Sector must ensure sustained advocacy to the Federal Executive Council, National Assembly and National Council on Health, for the continued upgrading of infrastructural facilities in Nigeria, including the completion of all Steel Plant in Nigeria; • Nigeria should aggressively promote and legitimize Public-Private Partnership (PPP) in all aspects of health in order to ensure sustainability, accountability and confidence building mechanism; • Efforts should be intensified to extend the provision of free health services to the aged, control illegal activities within the health sector by strengthening and increasing funding for regulatory agencies, and overcome harmful cultural practices within our communities; • Training and retraining of health workers must be intensified as an integral component of health sector development; • Periodic interaction with and between health sector workers must be encouraged, along with the constitution of a national Network for Health Sector Reform and Development that is participatory, action-oriented and involve the users; and • Improve the communication, funding, sharing and utilization of research results 49 NHC ABUJA 2006

  15. HEALTH CARE INDEX 51

  16. DEFINITION Health Insurance can be defined as a system whereby enrollees (subscribers) pay small contributions for the purpose of taking care of their sick minority i. e. the healthy majority taking care of the sick minority. 52

  17. TRANSITION PERIOD FOR SOCIAL HEALTH INSURANCE Germany - 1854 – 1988 Austria - 1888 – 1967 Belgium - 1851 – 1969 Luxemburg - 1901 – 1973 Costa-Rica - 1941 – 1961 Israel - 1911 – 1995 Japan - 1922 – 1958 Republic of Korea- 1963 – 1989 Ghana - 2003 – Tanzania - 2003 Nigeria - 2005 Source - Guy & Carrin – (Adapted) Health Finance Policy WHO/HQ – Geneva April 2004 53

  18. THE AMERICAN EXPERIENCE • SAME CHAOTIC SITUATION • EVER-RISING MEDICAL COST • RESOLVE BY EMPLOYERS TO COLLECTIVELY FIND SOLUTION • APPOINTMENT OF SOME DOCTORS TO RENDER DEFINED TREATMENT • UPFRONT PAYMENT INSTEAD OF FEE-FOR-SERVICE (THE MANAGED CARE CONCEPT) 54

  19. HEALTH INSURANCE SCHEME IN NIGERIA • - Bill introduced to the parliament in Lagos – Dr. Majekodunmi • 1984 – National Council on Health Commissioned a study on National Health Insurance • 1989 – Eronini Committee report was submitted and approved by the Federal Executive Council • 1992 – Directive that NHIS should Commence • 1997 – Formal Launching of the Scheme • 1999 – Enabling decree 35 – May 10 1999 • - June 6 – Flagging off the Formal Sector of Social Health Insurance Scheme by Chief Olusegun Obasanjo GCFR. President of the Federal Republic of Nigeria • 1. Core Ministries • 2. Parastatals and Agencies 55

  20. MEDICAL STATISTICS One in every four African is a Nigerian Nigeria accounts for 47% of the West African population Total Population 140 Million Annual Population growth 2.4% Urban Population percentage of total population 44% Life expectancy at birth 45 Infant Mortality Rate -100 for every 1,000 live births 56

  21. U5MR -201 out of every 1000 children born die before they reach the age of five Maternal Mortality Rate (MMR) 1500 out of every 100,000 live births 2 out of every 3 births happen at home 17% of women have no assistance during delivery 26% of women are assisted by an untrained person Only 13% of children aged 12-13 months have received the full course of immunization Access to improved water source – 57% WHO RATING 187/191 - 4TH FROM THE REAR 57

  22. OBJECTIVES OF NHIS • To ensure that every Nigerian has access to good health care services. • To protect families from the financial hardship of huge medical bills. • To limit the rise in the cost of health care services. • To ensure equitable distribution of health care costs among different income groups. • To maintain high standard of health care delivery services within the Scheme • To ensure efficiency in health care services. • To improve and harness private sector participation in the provision of health care services. • To ensure equitable distribution of healthcare facilities within the Federation. • To ensure the availability of funds to the health sector for improved services. • To ensure equitable patronage at all levels of health care. 58

  23. KEY PROVISIONS CAP 42.Of the Laws of Fed. Republic of Nig. Part V – Contribution, e.t.c 16 (1) An employer who has a minimum of ten employees may, together with every person in his employment, pay contributions under the Scheme, at such rate and in such manner as may be determined, from time to time, by the Council. (2) An employer under the Scheme shall cause to be deducted from an employee’s wages the negotiated amount of any contribution payable by the employees and shall not, by reason of the employer/s liability for any contribution (or penalty thereon) made under this Decree, reduce, whether directly or indirectly, the remuneration or allowances of the employees in respect of whom the contribution is payable under this Decree. 59

  24. STAKEHOLDERS TRIANGLE NHIS Employer (Federal Government) (10% Salary contributed) HMO A C B Employee Staff (5% Salary Suspended) Provider Hospital (U. C. H./Hospitals under NHIS Capitation on Monthly Basis 60

  25. Organisational Structure RegulatoryAuthority Government NHIS Health Management Organization HMO 1 HMO 2 HMO 3 Premier Medicaid Health CareProviders HCP HCP HCP 61

  26. COLLECTION AND DISBURSEMENT OF FUNDS Analysis of Financial Requirements of NHIS Page 35 Operational Guidelines One Enrollee 2%Admin - 13.3% Premium 3% NHIS - 15% - 1%Reserve - 6.7% 12% - 6% - Capitation - 40% Primary health care 3% - Secondary health care Fee for Service - 20% 2% - Administration - 13.3% 1% - Reserve funds - 6.7% Resource package or Brokerage -(20%) - 1.34% Reserve Funds - Reserve deposit -(30%) - 2.01% 6.7% Profit – dividends -(50%) - 3.35% Shareholders 62

  27. SERVICE STRUCTURE OF HEALTH INSTITUTIONS Funding Staff 63

  28. BURDEN OF DISEASES 64

  29. COMMUNITY BASED HEALTH INSURANCE SCHEME AS STRUCTURAL FOUNDATION RESEARCH TEACHING SERVICE 65

  30. IBARAPA COMMUNITY MODELADAPTED Stakeholders: 1. CHIS – Community Health Insurance Scheme 2. CHIF – Community Health Insurance Fund 3. HPA - Health Promoter Association 4. HPC - Health Promoter’s Card 5. HCP – Health Care Providers 6. HCA – Health Care Assistants 66

  31. COMMUNITY HEALTH INSURANCE SCHEME Health Advisory Council • Patron – Traditional Rulers/Community Leaders • Representative of: • FMOH • College of Medicine • Tertiary Health Institution • State Ministry of Health • Local Government • NHIS • HMO 9&10 2 Community Interest (HPA) 11 HCP/HCA Contributions - /Signatories • HMO • HPA 67

  32. RESOURCE MOBILISATION • Government Budget – Federal/State/LGA • External Sources/Diaspora • Private Donors/Entrepreneurs • NGO – Non-governmental Organisation • HPA – Health Promoters Association • Voluntary contributions (not tax) • Health fines Regulatory Framework • Collection of Revenue • Pooling of Resources • Purchasing Health • Servicom • EFCC • ICPC • NAFDAC 68

  33. ACHIEVING UNIVERSAL COVERAGE • Payment – determined by ability • Access – determined by Need NHIS Core Ministries Parastatals State Local Government CHIS 69

  34. Scaling Up Prepayment Schemes 45 - 75 • Acceptability Free Malaria Treatment • Replicability • Affordability • Sustainability • Accountability • Reliability • Comparability • Abolition of “Out of Pocket” Payment at the “point of service” 70

  35. MANPOWER • Health Care Assistants (HCA) (CHEW) MW • Health Care Providers (HCP) • Final year Medical Students (1/4 of HO’s Salary) • House Officers (Rotation) • NYSC Doctors • Final Part 1 NPMC/ (12months in CHIS) (12months Exchange Programme Overseas) • Consultant (CHIS Specialty) 71

  36. ADAPTABLE NIGERIAN MODELS • Health Promoters' Associations • Co-operative Societies • NURTW/Market Women • Community Farmers’/Traders’ Associations • “Egbe Imototo”, “Egbe Alafia” 58

  37. MODELS OF SUCCESS • INTERCONTINENTAL BANK PLC Private Health Insurance • Registration – gone up to 126% of the projected figure HOW? – • Abolition of Out of Pocket Payment – including co-payment • Abolition of limit of expenses • Conversion of Exclusions to Negotiables • Reimbursement of all expenses in Government Hospitals • Facilitation of Overseas Referral and Treatment 72

  38. UNIVERSITY OF BENIN TEACHING HOSPITAL • Registration gone up to 108% Reasons: • Aggressive Mobilization (CMD - Obstetrician) • Creation of NHIS Department with adequate Staffing • Co-payment deducted from NHIS Fund • Abolition of Out of Pocket Payment at the point of encounter • Department of NHIS support with basic IT apparatus 73

  39. ORGANOGRAM OF THE WARD HEALTH ORGANISATION (who). ROYAL FATHERS (or Community Leaders) HEALTH ADVISORY COUNCIL HEALTH PROMOTERS ASSOCIATION (HOUSEHOLD HEADS) Household Enrollees Household Enrollees Household Enrollees Household Enrollees Household Enrollees 74

  40. PROGRESS TOWARDS ACHIEVING THE MDGS • Eradicate extreme poverty and hunger • Halve the proportion of people living on less than US$1 a day • Halve the proportion of people who suffer from hunger • Achieving universal primary Education • Ensure that boys and girls alike complete primary school • Promote gender equality and empower women • Eliminate gender disparity at all levels of education • Reduce child mortality • Reduce by two-thirds the under-five mortality ratio • Improve maternal health • Reduce by three-quarters the maternal mortality rate • Combat HIV/AIDS, malaria and other diseases • Halt and reverse the spread of HIV/AIDS • Halt and reverse the spread of malaria and tuberculosis • Ensure environmental sustainability • Integrate sustainable development into country policies and reverse loss of environment resources • Halve the proportion of people without access to portable water • Significantly improve the lives of at least 100million slum dwellers • Develop a global partnership for development • Increase official development assistance, especially for countries applying their resources to poverty reduction • Expand market access • In cooperation with pharmaceutical companies provide access to affordable essential drugs in developing countries 1999 – UN baseline year 2015 – Target date for achieving goals 75

  41. Community Health Insurance Health of the People By the People and For the People. 77

  42. GOAL OF HEALTH INSURANCE Government Supported Community Driven Contribution at all appropriate levels of Government to fund CHIS Resources Mobilisation Risk Sharing Arrangement OUT of POCKET PAYMENT Barest Minimum 78

  43. Thank you for your attention! 79

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