NHIS SENSITIZATION FORUM 2013

1. NHIS SENSITIZATION FORUM2013

2. NHIS- A PATH TO UNIVERSAL HEALTH COVERAGE IN NIGERIA BY DR OLUFUNSO ANI,CLEARLINE INT LTD HEALTH MAINTENANCE ORGANISATION COURTESY OF (NHIS) At A ONE DAY SENSITIZATION WORKSHOP ORGANISED FOR FACULTY MEMEBERS @ LAUTECH DEPT FAMILY MEDICINE,OGBOOSO TUESDAY, 29TH OF OCTOBER, 2013

3. INTRODUCTION • Access to quality healthcare services is an important ingredient to nations’ development. • Where there is no health, there is no hope • This years topic – NHIS: A Path to Universal Health Coverage in Nigeria” is saying that everybody should have access to quality healthcare which is easily achievable via NHIS. • The hope of nation’s development will be dashed if health care of the people is not given adequate attention.

4. PURPOSE OF THIS PRESENTATION • To create awareness and understanding of enrollees and other stakeholders on how universal health coverage can be achieved. • To enlighten participants on the operational modalities of the scheme • To enlighten participants on the improved NHIS benefit package.

5. HEALTH STATUS • Health is not the mere absence of disease, but a state of complete Physical, Mental, Psychological and Social Well being. • Health status of any group of people have come to be seen as crucial not only to their wellbeing, but also represent a strong influence on the productive capacity of the people. • Not only has the financing of healthcare in Nigeria being on the decline, the various means of funding health services in the country are increasingly waning and becoming unavailable. • As a result, Nigeria health status indicator is among the worst globally; such that it ranked 187 out of the 191 UN member state (WHO 2000) • Poor funding of healthcare at all levels of governance

6. WHAT GOVERNMENT SAW. • This trend prompted the government of Nigeria to initiate the search for other means of funding health care that hitherto been neglected in the past. • Provision of healthcare in Nigeria is the responsibility of the three tiers of government hence the need for their collaboration. • Improving the health of Nigerians is a necessary pre-condition for achieving Vision 2020.

7. HOW CAN THIS BE ACHIEVED? • Through Universal Health coverage in Nigeria • This is achievable through world wide tested and trusted National Health Insurance Scheme [NHIS].

8. NHIS-PROFILE • An Agency of the Federal Government established under Act 35, 1999 to promote, regulate and administer the effective implementation of Health Insurance Programmes in order to ensure easy access to qualitative and affordable health care services to all Nigerians. • Started in 2005 with coverage of only the Formal Sector (Public sector) • Operated on a public/private partnership (PPP) basis • Based on social health insurance principles

9. NHIS VISION • A strong, dynamic, and responsive Govt. Parastatal (Agency) that is totally committed to securing universal coverage and access to adequate and affordable healthcare in order to improve the health status of Nigerians, especially for those participating in the various programs/products of the Scheme

10. NHIS MISSION • To facilitate fair-financing of healthcare costs through pooling and judicious utilization of financial resources to provide financial risk protections and cost-burden-sharing for people, against high cost of health care, through various prepayment's programs/products, prior to their falling ill..…in addition to providing regulatory oversight on HMOs and HCPs

11. Objectives of NHIS • To ensure that every Nigerian has access to good healthcare services • To protect families from the financial hardship of huge medical bills • To limit the rise in the cost of healthcare services • To ensure equitable distribution of healthcare cost among different income groups • To ensure high standard of health care services delivery to Nigerians • To ensure efficiency in healthcare services • To improve and harness private sector participation in the provision of healthcare services • To ensure equitable distribution of health facilities within the Federation • To ensure appropriate patronage of all level of healthcare • To ensure the availability of funds to the health sector for improved services

12. ADVANTAGES OF SOCIAL HEALTH INSURANCE • Provides a stable source of revenue for health • Improves resource pool. • Promotes solidarity- both risk and income solidarity • Maintains equity in financing and access • Combines risk pooling with mutual support • Cost effective • Frees up funds from govt. budget

13. ADVANTAGES OF SOCIAL HEALTH INSURANCE (2) • Age or health risk do not determine premium • Benefit rather than profit maximization • No restrictions in coverage • Ease of regulation • It is a paradigm shift with global acceptability. • In conformity with African social solidarity as depicted by the extended family system.

14. NHIS Mandate To achieve Universal Coverage of all Nigerians and Legal Residents by the Year 2015. Universal coverage has three dimensions • Service coverage (benefit-package) • Cost coverage (prepayment/cost sharing) • Population coverage (health for all).

15. ENSURING UNIVERSAL COVERAGE BY 2015 • The World Health Assembly discussion was on universal health coverage. • Given the mandate of universal coverage by 2015, is doable and achievable. • The dream of every Nigerian to have full access to comprehensive healthcare services through a realistic health insurance scheme by 2015 will come true if relevant stakeholders are made committed through legislation. • Secondly, if participation in the NHIS is mandatory for employers with up to 10 or more employees. • Apart from this, universal coverage will be achieved when it is made compulsory for all the population by amendment of the bill establishing the NHIS.

16. STATUS OF THE AMENDED ACT • The amended Act has gone for second reading in the National Assembly. • At present, it is with the Senate for it to pass through first and second reading.

17. STRATEGY OF ENSURING UNIVERSAL COVERAGE • One of the strategies employed to ensure universal health coverage by 2015 is the launch of the Voluntary Contributors’ Social Health Insurance Programme (VCSHIP) and the Community Based Social Health Insurance Programme (CBSHIP) to reach the informal group who largely lived in the rural areas.

18. VCSHIP • It is designed for political office holders, self-employed persons and Nigerians who can, of their choice, access care under the scheme. • VCSHIP is taken up and paid for at the discretion of willing individuals/employers on behalf of employees in organizations less than 10 staff. • Potential enrollees to be covered are requested to pay the mandatory contribution. This is done through the purchase of the of the Programme’s Scratch card from NHIS office at N15,000 ONLY PER ANNUM. • It will consolidate the success of the formal sector programme.

19. CBHI • It is a local initiative that build on traditional coping mechanism to provide small scale health insurance products specially designed to meet the needs of low income household. • It is a form of insurance that allow members to pay small premiums on a regular basis to offset the risk of needing to pay large healthcare fees upon falling sick.

20. Public Sector Social Health Insurance Programme (PSSHIP) Definition PSSHIP is a social security arrangement in which health care of employees is paid for from funds created by pooling the contributions of employers and employees in the public service.

21. Programmes of NHIS • Public Sector Programme (PSP) • Fed. Civil Service, • State Civil Service, • Local Government Civil Service, • Tertiary Institutions, • Military, Police and other Uniformed Services.

22. Programmes of NHIS cont. • Informal Sector Programme (PSP) • Rural Community • Urban Self-Employed • Voluntary Participants • Retirees • Organized Private Sector Programme

23. HOW THE PROGRAMME WORKS • The Enrollee gets himself/herself registered along side the spouse, four biological children under the age of eighteen years. • There is provision for more dependants or a child above the age of 18 years at a surcharge to be paid. • Enrolee chooses his desired clinic or hospital.

24. Who provide quality Health Services in NHIS Programmes? • Healthcare providers accredited by NHIS after inspection, which have the following: • Relevant professionals/Equipment • Legal corporate status • Be formally registered with the State and/or Federal-regulatory bodies • Must provide full, quality and professional service

25. Categories of health care Providers • Primary Health care providers - They act as first contact and gate keepers e.g. maternity homes, health centres, private/public clinics, OPD of Gen Hosp. e.tc. • Secondary healthcare providers -contact is only through referrals via primary provider. They include Specialist hosp., FMC, Gen. hosp., laboratories, Dental clinics, Radiography centres & physiotherapy. • Tertiary health care providers- entry is through referral via primary and or secondary provider. They include Teaching hosp. FMC, Military Reference hosp., Specialty/ Specialized hospital.

26. BENEFIT PACKAGE FOR PARTICIPANTS • Near comprehensive as possible • Packages include preventive, promotive and curative services • Prescribed drugs based only on Generic formulations • Three levels of care under NHIS i.e. primary, secondary and tertiary • Coverage is limited to Nigeria – no foreign treatment

27. BENEFIT PACKAGE (2) • Out patient care including necessary consumables. • Prescribed drugs, pharmaceutical care and diagnostic tests as contained in the NHIS Essential Drug List and Diagnostic Test Lists. • Maternity (ante-natal, delivery and post –natal) care for up to four live births. Additional care if any still birth • All live births eligible to cover will be covered during the post-natal period of twelve (12) weeks from the date of delivery.

28. BENEFIT PACKAGE (3) • All preterm/premature babies eligible to cover shall be covered for twelve (12) weeks from the date of delivery. • Preventive care, including immunization as it applies in the National Programme on Immunization, health education, family planning, antenatal and postnatal care. Adult Immunizations viz HPV, Hepatitis etc. • Consultation with specialists such as Physicians, Pediatricians, Obstetricians,Gynaecologists, General Surgeons, Orthopaedic Surgeons, ENT Surgeons, dental Surgeons, Radiologists, Psychiatrists, Ophthalmologists, Physiotherapists etc.

29. BENEFIT PACKAGE (4) • Hospital care in a standard ward for a stay limited to cumulative 21 days per year following referral. • Eye examination and care, the provision of low priced spectacles but excluding contact lenses • A range of prostheses (limited to prosthesis produced in Nigeria) • Dental care – preventive and promotive oral care (dental check, scaling and polishing, minor oral surgeries, maximum of 2 root canal treatment, replacement of maximum of 4 dentures, all dental cases that cannot be handled at the primary level • Nationwide cover in case of Emergencies • Additional Cover can be provided on demand.

30. EXCLUSIONS UNDER THE FORMAL SECTOR PROGRAM • Occupational/Industrial injuries are covered in the Workmen Compensation Act • Injuries resulting from natural disasters. (earthquake, landslides). Conflicts, social unrest, riots, wars; extreme sports – car racing, horse racing, polo, boxing, wrestling. • Epidemics. • Family planning commodities, including condoms • Drug abuse/addiction • Domiciliary visit. • Surgery – mammoplasty

31. EXCLUSION CONT’D • Transplant and cosmetic surgery • Provision of contact lenses • Treatment of congenital abnormalities requiring advanced surgical procedures e.g. TOF, ASD, VSD • Anti-tuberculosis drugs. • Artificial insemination, including IVF and ICSI • Dental care – crowns & bridges, bleaching, implants • Post Mortem examination

32. EXCLUSIONS CONTD. • Infertility management • Dentures and implants, S & P • Maxillo-facial surgeries • Meals and amenities/private wards Partial Exclusions • High technology investigations, except in life-threatening emergencies e.g. CT scan, MRI: The HMO would pay 50% of cost. • Dialysis for acute renal failure (max. 6 sessions) • PSA, Pap smears, mammograms have partial exclusions as HMOs pay 20% of the cost (these are screening procedures)

33. RESPONSIBILITIES OF NHIS • Setting standards for the operation of the programmes. • Regulates HMOs, HCPs and other stake holders by setting standard for them • Setting standards for Health Care Providers, HMOs and other stakeholders. • Carry out regular actuarial studies to guide operational reviews to determine contribution rate • Payment to Service Providers through the HMOs • Ensures that enrollees rights are preserved • Quality assurance through accreditation of all stakeholders

34. RESPONSIBILITIES CONT. • IEC to generate awareness on the Programmes • Collaborating with HMOs for the purpose of registration of enrolees • Developing Standard Treatment Protocol. • Sign MOU with the State • Supervision and monitoring. • Ensure enrollees rights are preserved

35. Roles of Health Maintenance Organizations (HMOs) • Register enrollees • Produce ID cards • Pay capitation to providers • Ensure quality assurance

36. Roles of Health Care Providers (HCPs) • Provision of quality health services in line with NHIS guidelines • Submission of regular report to NHIS • Procurement of professional indemnity for health care workers in their employment.

37. Roles of Participants • Acceptance of the Scheme • Making Contributions • Availing selves for registration • Freedom to choose Primary Health Care Provider • The responsibility to complain about the quality of care they access • To be Good Ambassadors of NHIS

38. CONCLUSION TheNational Health Insurance Scheme if properly implemented will provide answers to most of health problems in this country. Health care can be unpredictable for anyone and can be very costly. However, relatively few people will need healthcare at any particular time. It is by pooling the risk of large healthcare expenditures over many people that Health Insurance can make the necessary healthcare affordable to all participating contributors.

39. CONLUSION Contd. The blue print we have is not and cannot be perfect. The blemishes will gradually manifest themselves with time and will be appropriately dealt with. Our attitude as stakeholders should always be guided by the collective desire to improve the well being of our people thereby reducing the incidence of death from “brief illness” and ultimately increasing the abysmally low life expectancy of average Nigerians.

40. THANK YOU