DEDICATION This lecture is dedicated to Dr

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 HEALTH CARE PROVIDERS Risk Sharing Entity Out of Pocket Payment General Taxation Tax Collection (Prepayment Scheme) 5 Social Insurance Social Health Insurance (NHIS) Private Insurance Informal Sector Private Health Insurance Community Health Insurance (CHIS) HEALTH CARE CONSUMERS 37

WHO Geneva 1999 38

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

Brouwere 2001 40

CAUSES OF MATERNAL DEATHS GLOBAL ESTIMATES WHO Geneva 1999 41

Causes of Death in First Month of Life Lancet 2005 42

Adverse Consequences of Malaria in Pregnancy Malaria Pregnant Women Parasitemia Spleen Rates Morbidity Anemia Fever illness Cerebral malaria Hypoglycemia Fetus Abortion Stillbirths Congenital infections Newborn Low birth weight Prematurity IUGR Malaria illness Puerperal sepsis Mortality Severe disease Hemorrhage Mortality Effective Interventions 1. 2. Intermittent Preventive Treatment (IPT) Insecticide-treated nets (ITNs) 3. Case Management J. E. YARTEY 2006 43

WORLD HEALTH ORGANISATION 2000(RANKING) • NIGERIA-187 OUT OF 191 COUNTRIES. • A NATION IN MOURNING PLANE CRASH: ADC, BELLVIEW, SOSOLISO • PREGNANT WOMEN 150 • CHILDREN 15 O EVERY ALTERNATING DAY ADETOKUNBO LUCAS 2 OO 6 44

Collapsed Building due to Lack of Appropriate Structural Framework 45

UNITED NATIONS DEVELOPMENT PROGRAMME(RANKING)2006 Country Human Development Index Rank Expectati on of Life Under 5 Mortality Rate 2004 Maternal Mortality Ratio Ghana 136 56. 7 112 540 Cameroon 144 45. 8 149 730 Togo 147 54. 2 140 570 Kenya 152 47. 0 120 1000 Nigeria 159 43. 3 197 800 Benin 163 53. 8 152 850 Ivory Coast 164 46. 0 194 690 Chad 171 43. 6 200 1100 Sierra Leone 176 40. 6 283 2000 Niger 177 44. 3 259 1600 46

HEALTH STATUS TODAY 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 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 47 There is disconnect between research findings, dissemination and utilisation

WAY FORWARD 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 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

WAY FORWARD 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 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 NHC ABUJA 2006 49

HEALTH CARE INDEX COUNTRY HRH MATERNAL MORTALITY UNDER 5 MORTALITY Niger 0. 30 920 265 Togo 0. 30 980 141 Benin 0. 34 880 158 Cameroun 0. 45 720 155 Ivory Coast 0. 55 1200 175 Ghana 0. 93 590 100 Nigeria 1. 45 1100 183 51

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

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

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-FORSERVICE (THE MANAGED CARE CONCEPT) 54

HEALTH INSURANCE SCHEME IN NIGERIA 1962 - 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 2005 - 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

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

U 5 MR -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 - 4 TH FROM THE REAR 57

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

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

STAKEHOLDERS TRIANGLE HMO 60

Organisational Structure Government NHIS Regulatory Authority Health Management Organization Health Care Providers HMO 1 HCP HMO 2 HMO 3 HCP Premier Medicaid HCP 61

COLLECTION AND DISBURSEMENT OF FUNDS Analysis of Financial Requirements of NHIS Page 35 Operational Guidelines One Enrollee Premium 15% - 3% 12% - 6% 3% 2% 1% - Reserve Funds 6. 7% 2%Admin NHIS 1%Reserve Capitation Primary health care Secondary health care Fee for Service Administration Reserve funds - 13. 3% - - 40% - 20% 13. 3% - 6. 7% Resource package or Brokerage -(20%) - 1. 34% Reserve deposit -(30%) - 2. 01% Profit – dividends -(50%) - 3. 35% Shareholders 62

SERVICE STRUCTURE OF HEALTH INSTITUTIONS Funding Staff 63

BURDEN OF DISEASES Tertiary Care 5% Secondary Care 15% Primary Care 80% 64

COMMUNITY BASED HEALTH INSURANCE SCHEME AS STRUCTURAL FOUNDATION 65

IBARAPA COMMUNITY MODEL ADAPTED 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

COMMUNITY HEALTH INSURANCE SCHEME Health Advisory Council 1. Patron – Traditional Rulers/Community Leaders • Representative of: 2. FMOH 3. College of Medicine 4. Tertiary Health Institution 5. State Ministry of Health 6. Local Government 7. NHIS 8. HMO 9&10 2 Community Interest (HPA) 11 HCP/HCA Contributions - /Signatories – – HMO HPA 67

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

ACHIEVING UNIVERSAL COVERAGE • Payment – determined by ability • Access – determined by Need 69

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

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

ADAPTABLE NIGERIAN MODELS 1. 2. 3. 4. Health Promoters' Associations Co-operative Societies NURTW/Market Women Community Farmers’/Traders’ Associations 5. “Egbe Imototo”, “Egbe Alafia” 58

MODELS OF SUCCESS • INTERCONTINENTAL BANK PLC Private Health Insurance • Registration – gone up to 126% of the projected figure HOW? – 1. 2. 3. 4. 5. 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

UNIVERSITY OF BENIN TEACHING HOSPITAL • Registration gone up to 108% Reasons: 1. 2. 3. 4. 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 5. Department of NHIS support with basic IT apparatus 73

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

1. PROGRESS TOWARDS ACHIEVING THE MDGS Eradicate extreme poverty and hunger – – 2. 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 – 3. Ensure that boys and girls alike complete primary school Promote gender equality and empower women – 4. Eliminate gender disparity at all levels of education Reduce child mortality – 5. Reduce by two-thirds the under-five mortality ratio Improve maternal health – 6. Reduce by three-quarters the maternal mortality rate Combat HIV/AIDS, malaria and other diseases – – 7. Halt and reverse the spread of HIV/AIDS Halt and reverse the spread of malaria and tuberculosis Ensure environmental sustainability – – – 8. 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 100 million 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

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

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

Thank you for your attention! 79