Transcript Slide 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
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 MORTALITY IN SRI
LANKA 1940 -1985
Maternal deaths per 100,000 livebirths
1600
1400
1200
1000
800
600
400
200
0
1940-45 1950-55
1960-65
1970- 75
1980 -85
WHO 99020
39
Brouwere
2001
40
CAUSES OF MATERNAL DEATHS
GLOBAL ESTIMATES
Unsafe
abortion
13%
Obstructed
labour
8%
Other direct
causes
8%
Indirect
causes
20%
Eclampsia
12%
Sepsis
15%
Heamorrhage
24%
WHO Geneva 1999
41
Causes of Death in First Month of Life
Congenital
7%
Other
7%
Sepsis/
pneumonia
25%
Asphyxia
26%
Tetanus
7%
Preterm
25%
Lancet 2005
Diarrhea
3%
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
15O EVERY ALTERNATING
DAY
ADETOKUNBO LUCAS 2OO6
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
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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;
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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
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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
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
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%
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
80
Tertiary
(Federal)
Funding
Staff
Staff
Fund
Disease
15
Secondary
(State)
Primary
(Local)
Staff
Fund
Disease
5
Staff
Fund
Disease
63
BURDEN OF DISEASES
Tertiary Care
5%
Secondary Care
15%
Primary Care
80%
64
COMMUNITY BASED HEALTH
INSURANCE SCHEME AS STRUCTURAL
FOUNDATION
Tertiary
5%
Secondary
15%
Primary
80%
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
 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
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
Household
Enrollees
Household
Enrollees
Household
Enrollees
74
PROGRESS TOWARDS ACHIEVING THE
MDGS
1.
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 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
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