Lagos State will in the next few months roll out its mandatory health insurance scheme targeting 24 million residents of the state. In an exclusive interview withÂ Martins Ifijeh, the Commissioner for Health, Dr. Jide Idris, explains the nature of the scheme and how Lagosians can benefit from it
We are aware Lagos State health insurance scheme is about to kick off. How will you ensure poor Lagosians are covered?
Basically, the insurance is targeted at the poor. The principle behind it is to mobilise funds from different sources so as to cover the poor too. This mean they will no longer have to dig their hands into their pockets to pay for healthcare. It is a contributory scheme.
On specific reference to the poor, there is a provision in the law which states that one per cent of the consolidated revenue will also go into that fund. It is an equity fund that would take care of the poor and vulnerable. What we will make sure of is that the system must be able to determine specifically how to measure the level of poverty, so that the poor will truly benefit from the scheme.
How will you then determine those who are really poor?
Well, itâ€™s a difficult thing to measure, but what we have now is the tool and its statistics-base. It has been used in some countries before to address some factors related to poverty, to get scores and data that give an idea of poverty level in a country. That is what we are going to try out now.
For the fact that a large number of people will contribute to this fund, we are trying to focus for now on issues that can be taken care of in Primary Healthcare level. You know primary healthcare is the back bone of any healthcare system and if we can effectively deal with that level of care, we would have succeeded in taking care of about 37 per cent healthcare burden in the state. That is why basic care is being addressed.
Another thing we are doing is to increase the number of providers available. We are not limiting this scheme to only public facilities, we are also making use of private facilities, which are much more than public facilities get involved. This will mean people will not have to trek long distance before they enroll in any facility. On this scheme, access is key.
Whatâ€™s the nature of the scheme, will it be mandatory or optional?
Our scheme is different from the National Health Insurance Scheme (NHIS). The fact is, any health insurance scheme that is not mandatory will never succeed. Thatâ€™s the more reason the coverage at the national level has been very low, because we are in a developing country. People will naturally not want to pay for their health and I donâ€™t know why. People insure their cars, but wonâ€™t insure their lives. Ours is a mandatory scheme because thatâ€™s the way you can get people involved. But this requires that we explain to people why they need to pay for health insurance. One of the reasons is, people will pay when they are convinced that they will get the service.
That is why we have piloted this scheme in four communities, and it has been successful. So with it we now have an idea of challenges to face when we roll out fully. The fact is that once people have confidence in you, they will pay.
Take for instance, the poor people who go to Traditional Birth Attendants (TBAs) they pay. When they go get drugs, they pay. Study has shown that money in the sector is from private pockets. The essence now is to channel those resources properly so that they can get quality healthcare. Again, by law it is mandatory, but how do we want to enforce it? If we look at the rules of enforcement and regulation, you donâ€™t start using the big stick. People must understand what you are trying to do and it is by then they will willingly change their behaviour. When we started in Isheri community, people were reluctant, but we went there for about six months explaining to them. It got to a point they were willingly to pay extra to have extra service.
At a point, there was free healthcare in Lagos State, how will this scheme be different from that?
The free healthcare is one form of healthcare financing, but we know it wasnâ€™t free. There is no way government will fund free healthcare the way it is supposed to be funded. When this scheme starts, free health stops. And thatâ€™s why we are concerned that for those who are really poor, we will pay their own contribution in that equity fund.
What are the roles of ICT in making this scheme work?
Truly theÂ workers will work but without Information and Communication Technology (ICT), we will not get it right. That scheme is supposed to link the providers of care, people receiving care, the health management organisations and then the agency. It is a scheme that links everybody together and collates data. If we donâ€™t get that right, we are bound to fail. But we are almost through with the ICT.
We have built an infrastructural architecture for the scheme base on about 21 modules, and we have finished almost 18 modules. The last is linking all these things aforementioned and testing it, thatâ€™s whatâ€™s left. One of the problems we had was to go on a study to know how much we will tell people to pay, how much we fund and what to cover. We thought it was something we could get from the national level but we discovered they didnâ€™t have that, so we had to start afresh. I want to also say that in this environment, data is a major issue. What we have wonâ€™t get it perfectly right but once we get our ICT system, we are going to keep data and will keep building on it to assist us.
How do you intend to bring everybody into the health scheme?
To start with, the law says it is mandatory for every resident of Lagos State. The law says we should use Lagos State Resident Registration Agency card but we wonâ€™t wait for that because when LASRA started, it was for people of age 18 and above. For the health scheme, we are starting from age 0. So that software needs to be amended so that it wonâ€™t delay us. We will start with something else. Secondly, itâ€™s compulsory for civil servants and members of the public. For those who are on employment, itâ€™s easier. And those self-employed will have to be involved because some of them make more money than those in the office. They have to contribute because it is mandatory.
How would you make those in the informal sector and self employed contribute to the scheme?
Thatâ€™s why one of the things we have been doing is bringing all the different stakeholders in different groups together. We have been meeting and discussing with them on what their roles and benefit will be, and the feedback has been positive. Another thing is that enrollment will be by family, so that the larger the group, the cheaper you pay.
Our payment will be N40,000 per annum for a family of six. If you break it down per month it becomes N500 per person. Itâ€™s a matter of pulling. That agency now will manage the fund in a very effective manner to purchase care for those who enroll with the providers. And providers must meet strict criteria because part of that is to ensure quality of care. So when we increase the number of providers at the primary healthcare level, the people would have the choice of who their provider should be. Not that they will go to a general hospital and queue for hours. Choose a primary healthcare provider, whether private or public that you are familiar and friendly with, and if you are not happy with that person, you are free to change.
For the civil servants, they are all residents of Lagos State. In agreement with them, government will be pay 75 per cent of their own contribution while they will be paying 25 per cent from their salaries into that fund. That fund is special and will never come under the bureaucracy of government because we need to pay the providers so we donâ€™t have any break in transmission.
There are some people in the private sector who are already enjoying that level of insurance. We are not going to bother them but the idea is to put most of those that donâ€™t have any insurance at all into the scheme and they are many, almost 95 per cent.
The insurance scheme is to provide access and quality of care, to ensure that the poor are taking care of. The agency is supposed to manage the funds, it will comprise people who are good fund managers. We were using health insurance agents who already have the experience. So they can relate better with the providers and the enrollees and the agencies. We want to discourage cash collection so we are going to make use of different platforms available to make it easier for the people. Itâ€™s a complex thing, but the key thing to put everything together is ICT infrastructure.
What is the role of private sector in the health scheme?
We have more private sectors now as providers. Most of the HMOs are private, and there are some private facilities also using the HMOs. What are trying to do to make these things easier for them is to create a platform for manufacturers to have a link so that they can ensure adequate supply. We donâ€™t get involve, but between them, they will arrange for that. Which is another means of efficiency to show the private sector is fully involved, the ICT is also private sector driven
When you start the scheme, how would you ensure quality of service?
Quality of care is inbuilt in the scheme from day one. If any facility doesnâ€™t meet up to the standard required, they will not provide service. Itâ€™s not like we are just empanelling any provider, but first they have to apply, then we will go and inspect. We have a tool in the health accreditation agency, itâ€™s those tools that will be used to access readiness as a provider. There are two requirements they have to meet. One, they must be accredited by Health Facility Monitoring and Accreditation Agency (HEFAMAA). Secondly, we will know the staff strength of providers, bank account and BVN to ensure if money is transferred to them, they make use of it judiciously. One of the things we are insisting on is that for any provider whether private or public, each personnel must be Basic Life Support (BLS) certified. It is more or less like what is called Cardiac Pulmonary Resuscitation (CPR). That is, if someone comes in and collapses, you must be able to rescue that person, to ensure life is maintained, itâ€™s part of the requirement. We are aware some of them do not have the capability, but we will give them enough time to build that capability, its mandatory.
Another thing we will be looking into later in the future is to ensure they know how to deal with emergencies and if you donâ€™t have that capability, you know where to refer to. Those are the key issues of quality as requirement. The agencies, HEFAMAA and even the HMOs too will monitor the activities.
For 12 years that NHIS has been on, we have only had about five million Nigerians registered to it. Do you intend to make Lagosâ€™ scheme bigger than the national. What is your projection?
It is mandatory that every Lagosian has access to health service. So our focus is that the 24 million people living in Lagos are covered. Thatâ€™s the focus, so we canâ€™t go beyond our population. We also understand that we will have to reach our population over a period of time. So we are not starting with 100 per cent. We will start with the number we can manage now, then when we are able to convince them better they join the train. If we can cover about 75 per cent of the population we will consider it a success, but our target is to get to 100 per cent. You know people still move into Lagos every day and thatâ€™s why residency is an issue, when they come in they increase the burden which we need to address. Luckily, the federal government is also planning to make NHIS mandatory, which is also better.
We know for it to be mandatory, it has to be a stick and carrot approach. What is the stick approach?
The stick approach is that there is a law on ground mandating it, but we will not wield the big stick now. We will continue to educate the people. That is why we have been taking time to educate the different stakeholders. They have been making useful suggestions as well, which we have inculcated into the scheme. As people get more enlightened, enrollment increase.
How will this scheme impact on Lagosians?
It will impact on Lagosians in many ways. They will have better quality and access to healthcare services. This will reduce the cost of care while better service is offered. This scheme will reduce mortality and morbidity rate in Lagos, with emphasis on disease prevention, health promotion. Poor Lagosians will better be protected and better positioned to seek employment because they can take care of their health. Government funding will then take care of public health issues. We will build infrastructure that will be able to contain disease occurrence and train staff better. The health insurance scheme is a game changer for the sector. And thatâ€™s one of the key building blocks of any health system.
How far will this scheme cover? Will it be addressing cancers, kidney diseases, among others?
Under the law, we have three plans. We are starting with the basic plan, which will address primary healthcare issues. Commonly seen diseases like malaria, immunisation, delivery and the likes. We donâ€™t want our mothers and their newborn to die. We will not treat cancer but we will screen for cancer so as to be able to catch it early and then refer.
We will screen and treat common hypertension, because all these little things, if they donâ€™t get big, they wonâ€™t be expensive to treat. We will tackle emergencies to save lives. There will be huge emphasis on health promotion, immunisation and family planning. We will provide consumables to reduce maternal mortality and morbidity. As the scheme blows up, people will be able to pay for higher services because if we start from the asking them to pay big, they will kill the scheme from day one. A lot of these chronic diseases stay so for life. So the best thing is to catch them early before it turns something big and expensive.
When is the scheme rolling out?
We are starting this first quarter.
Apart from this insurance scheme, what other new things are we expecting in 2018?
We are introducing again the second phase of our health system reform. Government has invested hugely in terms of infrastructure but the outcome is not what we desire. So there is a problem with the process. What we want is quality of care and patient satisfaction. Another thing is we want to train our health workforce. Apart from ongoing renovation of our facilities at different levels of care, we will also be training our staff.
This year, we will be going fully on our defenses for infectious diseases. We will improve on surveillances. Lassa fever is around again and we donâ€™t know what will happen next, but we know it will happen and we must be prepared. If you look at Yaba where we used during the Ebola case, with the support of the Canadian Government, we are putting up the Bio safety free lab with the capacity to diagnose and treat some serious infectious organisms we can diagnose.
We need to address the issue of lifestyle and thatâ€™s where the role of people comes in. There is no point adopting negative lifestyle that will affect your health. People who have bad lifestyle like smoking could also cause problem for second hand smokers. So if we address the issue of unhealthy lifestyle like smoking, alcohol injection, among others, which are risk factors for diseases, we would have succeeded in reducing disease prevalence in the country. And all these things are risk factors for disease. They are the major cause of heart diseases, strokes and all. So we need to control those behaviours and modify good lifestyle.
While government is doing its bit, the public should also play their role. When they say donâ€™t drive without your seat belt and you refuse, something happen to you and you were taken to the hospital, supposing you donâ€™t have an insurance, you will pay from your pocket which will be expensive. Let us shift the focus to behavioural change.
Lagos is experiencing scarcity of health workers. Are you planning to address this?
Lagos does not have scarcity of health workers. If you say itâ€™s inadequate, I will agree with you because it is a major problem not only in Lagos State, but in Nigeria and in most parts of the world. Ours is coming to the fore because of our population. There is no government that provides the needed money in employing all the staff required. We are addressing this. We are still employing. The hospitals we are planning now will be staffed. That is why in the insurance scheme we said we will use both public and private facilities, because private has huge resources that are not being utilised.