Dr. Peju Adenusi is the General Manager, Lagos State Health Management Agency. In this interview with select journalists, she said Lagosians enrolled into the state’s health insurancescheme will have unfettered access to quality basic healthcare across. She also spoke on other benefits of the scheme, among other sundry matters. Martins Ifijeh brings excerpts
How is the Lagos State Health Scheme different from the National Health InsuranceScheme?
The Lagos State Health Scheme (LSHS) came about through a law that was enacted in 2015 and that law makes health insurance mandatory for every resident of the state. The main objective is to provide quality healthcare services which is accessible and affordable to the residents of Lagos State, and in so doing, reduce, if not eliminate the financial catastrophe that arises from huge medical bills.
Three entities were derived from the law. We have the LSHS which is the programme, we have the Lagos State Health Management Agency, (LASHMA), which is the agency that has been established to supervise and coordinate the scheme activities, and we have the LagosState Health Fund (LSHF). It serves as a basket of funds with various sources.
When we talk about health insurance, insurance generally, is a relative new concept to us in Africa and Nigeria is not an exception. Insurance is just a culture that we are not used to andhealth insurance is not an exception. When you tell people to come and pay money for ahealth event that can take place in the future, the quickest thing that comes to mind is that there is a sickness/illness, so why do I want to pay for a sickness in advance? Am I praying for illness? And with our religious background, the first reaction would be God forbid, I reject it, it is not my portion. So, it becomes very hard to convince people. But the irony is that it is a practice that is common among us, but we don’t know that that is what we have been doing.
For instance, if someone in a group runs into trouble related to health and that person can’t afford it alone, that person would rally round and people would begin to contribute money for him or her. So the concept is there with us. Health insurance is just putting that practice that is already with us in a structured manner. It is a communion thing. It is a form of solidarity.
From what I have said, you know that those that are worst hit are the vulnerable that is where the issue of equity comes in.
Just as it is on the global movement, we are talking about Universal Health Coverage, (UHC), so that means everyone should have access to health, regardless of their background, and one of the ways of achieving this is through health insurance.
Does the scheme cover all illnesses?
There is no health insurance programme that covers all health conditions and for us also to be able to demystify the issue of insurance that it is only for the sick, pregnancy is not sickness, and that is why I like using the word health condition. Going to the hospital to give birth is not a bad thing. That is something that is exciting and we all look forward to and we can also say that this is something that is planned, but there are other health conditions that come and are not planned for. Sickness does not write to anyone to say I am coming. So when it comes, there has to be a way to cover the cost that may arise from such condition.
Considering all these, the government looked at the common ailments that make people access hospital and can actually cause financial burden; they are malaria, common childhood diseases that are preventable through immunisation, common diarrhea, and the long communicable diseases like hypertension, diabetes and all the services that can be rendered at the primary healthcare level.
You talked about the PHC aspect of health, have you put proper structures in place at that level that can accommodate enrollees?
In Nigeria, the healthcare delivery systems are in three levels, the primary, secondary and the tertiary level. And also, services can be rendered from two different sectors, the private sector and the public sector. Studies have shown that out of pocket expenses attribute about 70 per cent of the healthcare cost in the country and about 70 per cent of these services are provided through the private sector, so in coming up with the scheme, we had to take that into consideration. So for the service provision, we are engaging both the public and the private healthcare facilities.
When I talked about PHC level, I was referring to the kind of services that are to be rendered. For this scheme, we are also collaborating with the Health Facility Monitoring and Accreditation Agency (HEFAMAA). They are responsible for licensing facilities to even practice at all. However there is the other aspect of their mandate which has to do with quality assurance. HEFAMAA already is undergoing some sort of restructuring and they actually partnered with one of the technical partners who helped in developing a tool that is tailored to the needs of LASHMA for facilities to come on board the scheme.
So there is a process. So the fact that you have a facility, whether public or private does not make you come in automatically and let us also remember that for facilities to join thescheme, it is voluntary, so you have to indicate interest. Once you have indicated your interest, HEFAMAA does an assessment on your facility based on the tool that is developed to ensure that you meet the minimum standard requirement to come on board. It is only when you scale through that assessment, that HEFAMAA recommends such facility to LASHMA, which will also do what is called revaluation visit.
Can residents be permissible to enter into more than one facility?
No. The reason is once a facility is on board it is not a once and for all time. It is a growing list because we have over 3000 healthcare facilities both public and private facilities in LagosState and the accredited facilities on our websites are just like 100. So more will be coming, more are already approaching LASHMA and they will have to pass through the normal process for them to come on board. The fact that you are accredited to come on board does not mean you will be there forever. It is expected that you improve your services because you came in with the minimum requirements. HEFAMAA also have the quality assurance responsibility and they will be working to ensure that the facilities maintain a high quality. Enrollees can only make a choice of one because of the way the scheme is designed.
How much are enrollees paying to be on the scheme?
The premium is N40, 000 per year for a family of six because our unit of enrollment is family enrollment. Family here is defined as the mother, father and four children under the age of 18years. However, there is an accommodation for individual enrollment as not everyone that resides in Lagos has a family here. We have people who are living alone, so for single individuals, it is for N8, 500. We know that there are families that are larger than six, so every additional family member, that is less than 18 years, attracts N6,000 per person, per year, but if the person is above 18 years of age, then it will be N8,500 per person per year, remember the duration of the policy is for a year.
In a family of six, if the children are above 18 years, and they still want the family enrollment, that family will pay a premium of N40, 000 per annual and additional N8, 500 per person, per year. My children are above 18 years, what I did was to pay N40, 000 and pay N8, 500 for each of my children. If you have grandmother, aunty, nephews etc living with you, that are categorised as individual and not part of the family package and they are over 18 years, the premium is N8,500 per person, per year.
The NMA, at their annual general meeting, advised their members to get the facts right before participating in any state health insurance scheme, are you having any challenge with the Lagos State chapter of NMA?
Well, you are giving me information I am not aware of. Nevertheless, the unit of participation is at the facilities and not membership, it is not as an association. So you come as a facility. LASHMA is dealing with every facility as a facility. So if I am to answer your question, we have facilities coming on board. You can see the names of the facilities. So I have not encountered any challenges. There was an advert toward the end of 2017, asking facilities to indicate interest to come on the scheme. I told you that they have to express interest, it is not automatic, so you have to say, I want to be part of the scheme and as many that have said that and have been assessed by HEFAMAA and have scaled through the HEFAMAA process and have also scaled through the procurement process of Lagos State, are on board. Those who are yet to join have come to make enquires, we hear from them almost on a daily basis that they want to be part of the scheme and they are well informed on what to do to come on board.
Will a family already on a health insurance scheme still be mandated by Lagos State to be on its scheme?
If you are a civil servant in Lagos State, the health scheme is replacing the free healthcare and the government is paying 75 per cent of the premium. The civil servant will then be paying 25 per cent.
Just like any other residents in Lagos State, if you already have a private plan, nobody is going to say stop your plan. And also remember that the state health plan is just one healthplan which is the basic health plan. However, when a state says something is mandatory, I think it is the duty of the residents to come on board, if you now choose to have a private plan as a top up, fine.
But let us remember that we are also looking after the vulnerable group in the society and I think the people whom you are talking about that have private plan are the minority.
One of the hurdles facing NHIS happens when there are strikes, especially when enrollees are using public hospitals. How will LSHS address this?
There is a contract with every provider. And the contract says that you must provide healthcare services at all time. I have worked with government hospitals including some inLagos State under a scheme and when there are strikes, they continue to see patients. So LASHMA is not involved in any medical clash or strikes. Since we have an agreement with the provider, it is something that we can work at. We also know that the private hospitals outnumber the public hospitals in the state. The tendency really is that most people will probably be going toward the private clinics that they know and are close to them. But if you have to choose the public hospital, which there is no harm in doing so because at the public hospitals, we have qualified personnel and skilled doctors. We are not oblivious to the fact that strike can happen, but when the providers are signing their contracts, certain things will be laid out and clear.
Not everybody can pay N40, 000 at once, can it be paid installments?
What we are advocating for is once and for all payment. For those who can’t afford it, there is going to be a tool to dictate who is poorest. We have rolled that in Makoko and will be visiting about 63 slum areas where we are going to apply the tool that would identify the poor. Now the government is going to subsidise it, it is 100 per cent subsidy.
Where should LASAM and the media practitioners come in for the sustainability of thescheme?
Lagos State Accountability Mechanism group (LASAM), nongovernmental organisations and the media have roles to play if the scheme must succeed. They should do more of advocacy, creating awareness and sensitising the people.