Last Tuesday, the Lagos State Government arguably launched the biggest mandatory health insurance scheme in the country with a projection to have all 25 million Lagosians under its coverage. In this exclusive interview with Martins Ifijeh, the Commissioner for Health, Lagos State, Dr. Jide Idris, said the programme will drastically reduce poor health indices in the state, while poor residents will no longer worry about cost of healthcare. He also spoke on other sundry issues. Excerpts:
How will the launch of Lagos Health Insurance Scheme improve health of Lagosians, especially the poor?
A huge chunk of the scheme is directed at the poor. 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.
In preparation for the launch, we did a poverty assessment of some of some areas like Makoko as a pilot. We have a designed tool to know those who are poor. Their own contribution will be paid from that equity fund. Again, insurance is more like subsidisation such that the rich covers the poor.
Some key diseases like Human Immuno Virus (HIV) and Tuberculosis, which are common with the poor, will be financed by some organisations that have signified interest.
Are civil servants automatically put into the scheme?
Our law says every resident of the state must contribute. The issue of civil servants came up when we were marketing the scheme. They will be paying 25 per cent from their own salaries while government will pay 75 per cent as part of their contribution to the scheme.
Initially we settled for 73/30 ratio, but they later came back that they would love to do 75/25 ratio, which was okay by us.
Bringing this up at the heat of elections, don’t you think it is a ploy to bribe Lagosians into voting APC in the next governorship elections?
No. We have been on this for a long time. The concept started during the time of Asiwaju Bola Tinubu. We had to put it on hold because federal government wanted to centralise it. The committee Asiwaju set up then was headed by the late Prof. Ransome Kuti.
So at that time, we started with the free health coverage, but overtime we realised free health cannot work. No government can fully fund the health sector. So what governments are doing is to de-emphasise free health and reduce out of pocket payment. So it has nothing to do with politics. Sickness doesn’t know politics. As a matter of fact, we should have launched this scheme a year ago, but we needed to perfect our Information and Communication Technology (ICT) platform.
How is this scheme different from the free health programme the state has always had?
When in 1999 we realised we can’t afford free health because it requires pumping huge funds which government doesn’t have, we then narrowed it down to some specific issues for under five children, 65years and above persons and pregnant women. As a government we couldn’t implement it, because that alone will cost N8 billion a year. So there was need for government to look for alternative source of funding. 65 per cent of Nigerians pay out of pocket. So if we re-channel that into a proper scheme where everybody contributes, it makes things easier.
What are the basic problems this scheme will be covering?
The scheme has about three plans-basic, private and then general. We are starting with the basic plan which involves care at the primary healthcare level. Treatment of commonly seen conditions like malaria, typhoid, measles, including immunisation, counseling for non-communicable diseases like cancers, among others will be covered.
We are also focusing on maternal and child care because that’s part of where you have high mortality rates.
The National Health Insurance Scheme (NHIS) is voluntary, are you towing the line of the federal government, or is your scheme mandatory?
We realised the folly of the federal government, so we are not towing that line. 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. That is why for the poor, the equity fund will cater for them.
When we were planning the scheme, we looked at areas of challenge NHIS had, so we made ours mandatory. We will use Health Management Organisations (HMOs) and Health Insurance Agents (HIAs) because they have the expertise. We will be limiting their participation to some specific areas, for which we will pay.
How would you get the informal sector to buy into this scheme?
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 is a matter of them knowing what we are offering.
One of the major issues with states that have started their health insurance scheme is lack of proper ICT. Has Lagos taken this into consideration?
That is why we are even starting late. Because we needed to perfect the kind of ICT platform we wanted. You can’t run insurance scheme successfully without a robust ICT. The platform we adopted has been used in Kenya and Ghana. We went to Kenya to understudy it. We piloted it in two health facilities in Lagos and it worked. Our scheme is data driven, because it will connect the different players like providers, the agency, residents, and health insurance agents. There will be payment platforms to contribute their funds.
We are encouraging family enrolment as well; that is father, mother and four children. That way, it is cheaper. With N40,000 payment a year, you will realise each member is spending around N500 a month for healthcare. The ICT platform is to connect everyone to provide data for use, without which we can’t track anything. We will be tracking funds, commodity, etc.
Have you done a pilot study to show if this scheme will work?
We have piloted this pre-payment scheme in four local governments. If you recall, we had the community insurance scheme before this. The results showed it is workable and doable.
In one of the pilot we had in Ikosi Isheri, which is like a primary care facility, we got it refurbished and we got the private sector to provide service. People were enrolling and they paid. Cases that were not seen there were referred to Gbagada General Hospital. Surprisingly, in one of the town hall meetings, they said they won’t mind paying more if all services were provided in Ikosi. So it is something people have embraced.
Will you be using only government facilities as providers or are private facilities involved?
The concept of Universal Health Coverage (UHC) is one to improve access to care and quality of care. So we are not limiting it to government hospitals alone, because even private providers cover over 60 per cent of Lagos population. So one of the things we said we will do is to support them. All those interested. All those interested are encouraged to register. However, they must conform to our requirements, one of which is quality of care.
As a way to assist them, we established access to finance initiative, which we are piloting. It is a way of getting a number of financial institutions together to contribute so that they can provide loans to these private health facilities at a much cheaper rate. Before, now, banks would not provide loans less than 29 per cent interest rate, but we negotiated to nine per cent. Since people are contributing, they have a say. You can decide who you want as your primary healthcare provider, whether it’s public or private.
Population of Lagos is growing rapidly. Do you have the facilities to accommodate all residents into the scheme?
No country can provide health insurance 100 per cent even though we aspire to provide it. You know people are moving into Lagos because of what they perceive as better economy. So as they move, they have to conform to our law. You must contribute to the scheme which makes you entitled to the service.
Financial institutions do not normally fund the health sector the way they fund other institutions, but with what we are doing, they are beginning to have interest. When we guarantee you can pay that loan back they will give. We have also started teaching our providers how to manage loans, because if they pay back, they will get more loans.
Our law says periodically all stakeholders will sit down to examine progress and challenges. So as our population surges, we will deal with it. If insurance works very well, it means government can then use money this has freed up to address other public health issues.
Since last Tuesday, the real enrolment has started. When you enroll, we don’t automatically start treatment, we give about two weeks for equity sake. Access to care starts in January 2019. We presently have over 150 facilities ready. So we will be starting from local government to local government. Any local government that is ready will commence enrolment. First year, we will target 10 per cent of Lagos population, that is 2.5 million people, and then we will progress from there.
You have started a lot of enlightenment to educate Lagosians on the scheme; do you have laws in place to punish residents who do not subscribe to the scheme?
What we are more interested in is trying to change behaviour and mindset of our people. You don’t change that by force. You need to let people fully understand what you want to do. That is why we are doing a lot of advocacy. This is a way of gaining the confidence of the people. If you start using the stick, you are killing the scheme.
Regulation is a continuum, one is persuasion, the other is stick, what we are pushing is persuasion, because people are naturally not used to paying for health services. Nobody forces us to insure our cars or houses, so why can’t we insure our health. Many people are not insuring their health because they don’t fully understand why they should.
People contribute money for meetings as a culture; it is virtually the same thing. Those contributions they make in meetings help them, so will health insurance.
What is the stick approach if at all you decide to use it?
In that law, we try not to penalise offenders from day one, because now we are focusing on persuasion. But if after a while they refuse to pay, it means they are cheating people who are paying. We will have agents in each local government who will be enrolling people, moving door to door and market places, etc.
Do you intend starting with everybody resident in Lagos at once or bit by bit?
Starting with civil servants is the easiest, but the focus of UHC is targeted at everyone. So as we talk to groups, once they have the number they will enroll them.
We are doing it in stages, from local government to local government. From feelers, this will spur other local governments to sit up. As more providers apply to offer service, they are credited so targeting a particular group may not necessarily fulfill the spirit of UHC.
Can you break this scheme down in figures and numbers so that the ordinary residents will fully understand the benefits?
We will cover many people under many health services, and in doing so, we want to improve on our health services, for instance infant or maternal mortality. We can’t track this overnight, it will take some time.
Do you have a projection?
Yes we do. It will reduce infant mortality rate by 10 per cent over a period of time. That is why the ICT platform is very important because we will get data and use it to analyse data. We will do impact accessment. We have support from the Dutch government. We will collect data from the beginning, then periodically we track progress.
If we have more people into the health scheme, the projection is that the statistics will be better. If you have more children on immunisation it means it will be routine and not periodic immunisation. Once the people are contributing, they have a say. They can ask why they are not getting immunisation and all that, otherwise they report the provider. It’s more like a check and balance. If you contribute to something you have a say. Once you report your provider and we investigate it to be true, they are penalised.
For instance, when we discussed with pharmacists, they wanted their payment to be capitated. If you are paying x amount of money per person, so your role is to ensure they don’t fall it. If you immunise your children against diseases it means they don’t fall ill from that illness.
Will this scheme cover cancer and other major health issues?
Our plan is to start small. Primary healthcare level is the bedrock of any healthcare system, because this takes care of 70 per cent of all health issues. As this pool enlarges we can think of cancer and other major health issues. If you screen those with cancer how many can you put on treatment right now? The essence is to prevent them from having cancer.
Under the scheme, we screen for cancer and the likes. For instance, cancer of the cervix is related to infection. They can be given vaccines to prevent it. You can’t treat everything you have in this country, so don’t even attempt it, because this would wipe out the little funds you have.
In many meetings, you have talked about how this scheme is very dear to your heart. What if a new government comes in and stops or changes the scheme?
I am not even thinking about that. There is a culture of continuity in Lagos State. The governorship candidate for All Progressive Congress in the state was part of the committee that developed the scheme. A law has been passed on the scheme. If you run this programme for a while and the people like it, do you think someone can just come and change the law? The people will resist it. If you want to change such law, you first go to the House of Assembly to repeal it. The House will rather even listen to their people since it benefits them.