Nigeria: Ensuring Universal Health Coverage in Lagos

Efforts by stakeholders in the health sector towards evolving the best funding arrangement that can bring about universal health coverage (UHC) in the country have gathered momentum.

According to the World Health Organisation (WHO), UHC means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.

To this end, ahead of the Lagos State's mandatory health insurance scheme roll out, next month, senior executive course participants of the National Institute for Policy and Strategic Studies (NIPSS) took a study tour of health facilities and brainstormed with civil society organisations and other stakeholders on the state of affairs in the state's health sector.

The stakeholders were concerned with how Lagos and Nigeria as a whole can evolve the best funding arrangement that can make UHC possible.

It is believed that Lagos is not in a hurry to start full implementation of the scheme to avoid the mistakes that have marred similar initiatives in the country, especially the National Health Insurance Scheme (NHIS), which has failed to achieve UHC because the law setting it up made it optional for the people.

Having realised that countries that have achieved UHC for their populations are the ones that have successfully implemented mandatory health insurance schemes, many stakeholders in the nation's health have begun to campaign that state-supported health insurance schemes be made compulsory in order to provide coverage for all citizens.

Meanwhile, the study tour was facilitated by NIPSS in collaboration with the Development Research and Project Centre (DRPC) through Partnership for Advocacy in Child and Family Health at Scale (PACFaH@Scale).

The delegation visited the Lagos State University Teaching Hospital (LASUTH) and primary healthcare centres in Palmgroove, Mushin and Lagos Island. The visitors also paid homage at the palace of Oba of Lagos, Oba Rilwan Akiolu, before ending the tour with an interaction with civil society organisations (CSOs) that are working in the health sector.

Technical advisor, PACFaH@Scale, Dr. Stanley Ukpai, told journalists that the study tour was meant to help participants to find out how to strengthen primary healthcare system to achieve universal health coverage in the state. Through the tour, he added, the delegation was able to obtain feedbacks and inputs from on the challenges and opportunities of working within the primary healthcare system to realise UHC for the teeming population of the state.

On arrival in Lagos, the delegation's first port of call was the state secretariat in Alausa, where they met with key stakeholders and heads of strategic institutions in the state health sector on the state of affairs.

The study tour is part of requirements of the course programme at NIPSS. It is designed to help course participants to learn more about the nuances of public policy formulation and implementation. Depending on the theme of the course, participants in NIPSS programmes are expected to embark on national, continental and intercontinental study tours on any issue deemed critical to the country's development aspirations with a view to submitting actionable recommendations on best practices.

While expressing optimism that the state would benefit from the study tour, Oba Akiolu said he was delighted that the focus of the tour was to understand the challenges affecting healthcare delivery system in the state with a view to providing solutions. He acknowledged that qualitative healthcare system is vital to improved life expectancy, stressing that government should improve budgetary allocation to the health sector in line with recommendations of the WHO because there is a nexus between quality healthcare and economic development.

Leader of the delegation and acting director of studies at NIPSS, Dr. Nasirudeen Usman, said this year's theme focuses on how Nigeria can evolve the best funding arrangement that can bring about universal healthcare coverage in the country.

Commissioner for health, Lagos, Dr. Jide Idris, told the delegation that technology would be deployed heavily into the scheme to simplify the application process for enrolees, stressing that technology would be vital to the success of the scheme.

Idris stressed that the state government is currently creating awareness and capturing people into the scheme, adding a reliance on technology will help in the collection of data of those enrolled. "With this technology, many people will be easily captured and they can easily access the scheme through the mobile application," he said.

As the law setting up the scheme stipulates, all residents - regardless of their financial or educational status - are expected to be captured by the compulsory scheme, which aims to be the first programme that achieves universal healthcare coverage in the country.

Idris said no fewer than 120,000 persons have enrolled in the health insurance, though not all are actively enjoying the service for now.

To avoid the pitfalls of NHIS, Lagos has chosen to make the scheme compulsory for all residents.

"Countries that have successfully implemented health insurance scheme made it mandatory. Again, in those countries, a lot of money is being pumped into it, and then taxation is high so they can fund it. Our scheme is mandatory for every resident," Idris added.

The delegation commended the state for making the scheme mandatory. "That is the global practice; you cannot cover the whole population unless you make it mandatory. If we have compulsory insurance for our vehicles, we should be able to have compulsory health insurance for ourselves," Usman said.

The scheme, which was launched with fanfare last December by Governor Akinwunmi Ambode, aims to provide financial protection against illnesses and attendant uncertainties inherent in out-of-pocket payment system.

Besides being projected to reduce health issues or mortality rate in the state by at least 10 per cent, the governor said it would also deliver significant economic benefits to the state, as the statewide health insurance scheme will empower residents to have access to quality, affordable healthcare services.

"Beyond ensuring that we have a healthy population, the scheme will foster inclusion and an increase in the utilisation of hospital services, thereby creating employment opportunities for medical professionals. This will definitely have an impact on the economy of the state," Ambode said.

And to enjoy full access to services on offer, all that is required is a premium of N40,000 yearly for a family of six. A family, as defined by the law setting up the scheme, comprises the mother, father and four children below 18 years; while enrolling every additional family member below 18 years attracts N6,000 per person per year.

However, if the person is above 18 years, it attracts additional premium of N8,500 per person yearly. For single individuals, it is for N8, 500 per year, but this can be upgraded any time after marriage with additional charges.

As for employees in the state public service, the state takes care of 75 per cent of the premium, while each civil servant is expected to pay 25 per cent.

However, a consultant for DRPC, Obioma Obikeze, expressed concern over the payment arrangement for civil servants, stressing that workers at the lowest rung of the ladder will be disadvantaged if every state employee, irrespective of status, pays 25 per cent premium.

Having realised that the informal sector forms the bulk of potential enrollees, Lagos said it is doing everything to bring people in the sector on board.

"We are also meeting the key stakeholders in the informal sector, which constitutes about 65 percent of the population because if you don't enroll these people, this scheme will fail. We know the informal sector constitutes a huge chunk of the population, and that's where the real work is. We have mapping which has details of everyone in the informal sector.

Luckily, we have an agency of government dealing with them. We have met with the various union executives, and they have expressed interest. We also need to continuously reach out to them through persuasion. Some of them are already on one scheme or the other, but whether that scheme is better or not, it's a matter of them knowing what we are offering," Idris said.

And for the poor who genuinely may not be able to afford the premium, the Idris said an equity fund has been set aside to cater for them by subsidising the premium 100 per cent for the vulnerable.

"That is why the law establishing it says a minimum of one per cent of the consolidated revenue fund of the state will go into a pool, which is an equity fund basically to address people who cannot afford to pay. That is to guarantee a financial protection for them. The contribution of the poor will be paid from that equity fund," he explained.

On what specific items the health insurance cover, Provost, Lagos State College of Medicine (LASCOM), Prof. Anthonia Ogbera, said it takes care of common adult and childhood ailments, maternal and child services, preventive healthcare services, selected non-communicable diseases and surgeries. Ogbera lamented that poor knowledge of the scheme among residents may be the bane of the new initiative. "Raising more awareness is the "only way to make many people buy into the scheme," she said.

Unlike many states that have bought the idea of eliminating the middlemen called health management organisations (HMOs) in their health insurance schemes, Lagos has vowed to retain them, believing that HMOs have a vital role to play in deepening enrolment of the scheme by selling it directly to the people in all the nooks and crannies of the state.

According to the Chief Medical Director, Lagos State University Teaching Hospital (LASUTH), Prof. Adetokumbo Fabamwo, no fewer than ten HMOs will be engaged for the scheme, with each assigned its catchment areas.

"Registration is state-wide and that is why we decided to allocate HMOs to certain areas for ease of capture. If an HMO is said to cover Mushin for example, they will go out there and capture all the citizens of the area into the scheme because the higher the enrollees, the higher their capitation fee. If you tell people in Mushin to look for any HMO and join, enrolment will be slow.

For the formal sector, we gave them a choice of HMOs to choose, but for informal sector, we allocated HMOs to them so as to achieve one hundred per cent coverage," he said.

But many experts have also traced the abysmal failure of NHIS to the activities of HMOs, which serve as the link between the scheme and the service providers. Every quarter, NHIS disburses cash to HMOs, who in turn pay service providers monthly for health services of enrollees.

Tongues have, however, remained wagging over the performances of HMOs who have been accused of deliberately frustrating the scheme by reportedly not keeping to their own side of the bargain, leaving many service providers unable to deliver adequate care to enrollees.

Yet, almost half of a trillion naira has been reportedly disbursed to HMOs since inception of NHIS.

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