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THE NATIONAL HEALTH INSURANCE SCHEME WHICH WAY FORWARD? BEING THE TOPIC OF THE LECTURE DELIVERED

THE NATIONAL HEALTH INSURANCE SCHEME WHICH WAY FORWARD? BEING THE TOPIC OF THE LECTURE DELIVERED BY SIR, DR. KAYODE OBEMBE B.Sc. Med Sc, MBBS, FMCOG, FWACS, FIAMN, FAGP, FICS,DMP Hon. DG, M.O.W, J.P, KJW. Vice Chairman / Chief Executive Officer Premier Medicaid Int’l HMO DELIVERED

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THE NATIONAL HEALTH INSURANCE SCHEME WHICH WAY FORWARD? BEING THE TOPIC OF THE LECTURE DELIVERED

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  1. THE NATIONAL HEALTH INSURANCE SCHEME WHICH WAY FORWARD? BEING THE TOPIC OF THE LECTURE DELIVERED BY SIR, DR. KAYODE OBEMBE B.Sc. Med Sc, MBBS, FMCOG, FWACS, FIAMN, FAGP, FICS,DMP Hon. DG, M.O.W, J.P, KJW. Vice Chairman / Chief Executive Officer Premier Medicaid Int’l HMO DELIVERED UNDER THE AUSPICES OF THE NIGERIAN MEDICAL ASSOCIATION OYO STATE CHAPTER ON FRIDAY 9TH AUGUST, 2013

  2. 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

  3. Health Financing Mechanisms HEALTH CARE PROVIDERS Risk Sharing Entity (Prepayment Scheme) 5 Out of PocketGeneral Taxation Social Insurance Private InsuranceInformal Sector Payment Tax Collection Social Health Insurance (NHIS) Private Health Insurance Community Health Insurance (CHIS) HEALTH CARE CONSUMERS 37

  4. 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.

  5. 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

  6. 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-FOR-SERVICE (THE MANAGED CARE CONCEPT)

  7. HEALTH INSURANCE SCHEME IN NIGERIA • - Bill introduced to the parliament in Lagos – Dr. Majekodunmi • 1983- First International Conference on Health Insurance at UCH – Chairman – Prof. Oluwole Akande (Provost), Guest of Honour – Prof. Adeoye Lambo- Deputy Director General, WHO, organized by NARD, Dr. Kayode Obembe - President • 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 • - 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

  8. MEDICAL STATISTICS One in every four African is a Nigerian Nigeria accounts for 47% of the West African population Total Population 168 Million Annual Population growth 2.4% Urban Population percentage of total population 44% Life expectancy at birth 41 Infant Mortality Rate -100 for every 1,000 live births Maternal Mortality Ratio – 545 per 100,000 deliveries

  9. USMR -201 out of every 1000 children born die before they reach the age of five Maternal Mortality Rate (MMR) 545 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

  10. 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.

  11. PROGRAMMES OF NHIS • As part of the strategy for achieving universal coverage, the National Health Insurance Scheme runs the following programmes in order to ensure that every Nigerian has access to qualitative and affordable health care services:- • Formal Sector Social Health Insurance Programme. • Urban Self-Employed Social Health Insurance Programme • Rural Community Social Health Insurance Programme • Children Under-five Social Health Insurance Programme • Permanently – Disabled Persons Social Health Insurance Programme • Prison Inmates Social Health Insurance Programme • Tertiary Institutions and Voluntary Participants Social Health Insurance Programme • Armed Forces, Police and other Uniformed Services Programme. • Diaspora Family and Friends Programme. • International Travel Health Insurance Programme.

  12. National Health Insurance Scheme (NHIS) Highlights: • 1st Proposal submitted to parliament – 1960s • NHIS flagged off in all geopolitical zones of the federation • Every organization with more than 10 employees MAY participate • Public-Private Partnership (PPP) initiatives established • Health Maintenance Organisations (HMO) made to be grassroot managers • 7 HMOs were first accredited and PREMIER MEDICAID was one of them • The number of HMOs operating in the country is increasing on daily basis. At last count, they are above 60

  13. 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.

  14. OPERATIONAL GUIDELINES OF NHIS • Decree no. 35 May 1999 states that employers with more than10 employees are expected to join the scheme • 15% of basic salary – International Labour Organisation. 10% to be contributed by the employer and 5% by the employee. Spouse + 4 children

  15. STAKEHOLDERS TRIANGLE NHIS Employer (Federal Government) (10% Salary contributed) HMO A C B Employee Staff (5% Salary Suspended) Provider Hospital (U. C. H./Hospitals under NHIS Capitation on Monthly Basis

  16. MAIN ACTORS IN THE SCHEME • GOVERNMENT AS REGULATOR • PROTECT RIGHTS AND ENFORCES OBLIGATIONS • EMPLOYERS AS CONTRIBUTOR • CONTRIBUTES 10% OF 15% FOR EMPLOYEE • EMPLOYEE AS CONTRIBUTOR • CONTRIBUTES 5% OF 15% • PROVIDERS OF SERVICE - PRIMARY PROVIDERS TO SERVE AS GATE KEEPERS • SPECIALISTS – ON REFERRAL ONLY • FINANCIAL INSTITUTIONS (TO SERVE AS FINANCIAL MANAGERS) • PARTICIPATING BANKS • PARTICIPATING INSURANCE COMPANIES

  17. HEALTH CARE PROVIDERS (a) • GENERAL MEDICAL PRACTITIONERS • Possession of Bachelor of Medicine, Bachelor of Surgery (MBBS) or its equivalent recognised by the Medical and Dental Council of Nigeria. • Registration with the Medical and Dental Council of Nigeria • Possession of required Malpractice Insurance as may be determined from time to time by NHIS. • Possession of appropriate facilities for standard practice as determined by NHIS. • Possession of current license to practice from Medical and Dental Council of Nigeria (MDCN). • Registration of premises by the state in which it operates.

  18. HEALTH CARE PROVIDERS (b) • SPECIALIST DOCTORS • These include Physicians, Radiologists, Paediatricians, Psychiatrists, Surgeons, Gynaecologists, Ophthalmologists etc and the requirements include: • Possession of Bachelor of Medicine Bachelor of Surgery Degree (I.e. MBBS) or registerable equivalent, and recognised specialist qualification in the proposed area of practice. • Registration of primary and additional qualifications with the Medical and Dental Council of Nigeria • Possession of required Malpractice Insurance as may be determined from time to time by NHIS • Possession of appropriate facilities for standard practice in the field as determined by NHIS • Possession of appropriate equipment and staff to render standard service in their field of specialisation • Possession of current license to practice from the Medical and Dental Council of Nigeria (MDCN) • Registration of premises with State Government in which they practice.

  19. GENERAL REQUIREMENTS: HMO • REGISTRATION WITH CORPORATE AFFAIRS COMMISSION • PROVISION OF CERTIFICATE OF INCORPORATION, ARTICLES OF ASSOCIATION ETC • EVIDENCE OF FINANCIAL VIABILITY • MAITENANCE OF ACCOUNT WITH NHIS APPROVED BANKS • INSURANCE WITH NHIS INSURANCE COMPANY TO THE VALUE OF PAID UP SHARE CAPITAL • COMPLETION OF PRESCRIBED APPLICATION FORMS INCLUDING PROVISION OF THE FOLLOWING INFORMATION: • OWNERSHIP STRUCTURE • NAMES AND ADDRESSES OF THE PRINCIPAL OFFICERS • POSSESSION OF NECESSARY STAFF AND INFRASTRUCTURE INCLUDING COMPUTERISATION

  20. FINANCIAL REQUIREMENTS HMO • National - Share Capital N400million • Zonal - Share Capital N150million • The 50% mandatory deposit is held as security should the HMO default • All contributions collected by the HMO must be paid into NHIS appointed bank(s) • Remittance of 3% from the 15% collections to NHIS – 2% as administrative cost and 1% for reserve funds • After settling all obligations from the 15% contributions, the HMO is entitled to the surplus/(deficit) fund available as operational profit or loss.

  21. Organisational Structure RegulatoryAuthority Government NHIS Health Management Organization HMO 1 HMO 2 HMO 3 Premier Medicaid Health CareProviders HCP HCP HCP

  22. MISSION AND VISION: PMI • OUR MISSION THAT EVERY NIGERIAN SHOULD HAVE FACILITATED ACCESS TO EFFICIENT, EFFECTIVE AND QUALITATIVE HEALTH CARE ANYWHERE AND AT ALL TIMES • OUR VISION HEALTHCARE FOR NIGERIANS AT AFFORDABLE COST THUS IMPROVING THEIR ECONOMIC RESOURCE POTENTIAL AND QUALITY OF LIFE.

  23. AIMS AND OBJECTIVES: PMI • 1.To inculcate the awareness of the need for health insurance as a means of planned managed health care system. • 2. To convince the audience of the benefits bilaterally derivable for the parties concerned

  24. Premier Medicaid Health Scheme • Premier Medicaid offers specifically designed Health Plans for specific group of Health care consumers Benefits • Guarantees 30% cost reduction in their health budget • PM Health Care providers are screened to make sure they meet international standard • Employees receive prompt attention • Risk Management The Company • Health Insurance envisioned since 1986 • Incorporated specifically for Health Insurance Scheme • Mandatory Bank deposits paid to guarantee the safety of funds paid by customers

  25. PRIMARY LEVEL SURGERY • DRAINAGE OF SIMPLE ABSCESS • WOUND DEBRIDEMENT • SURGICAL REPAIR OF SIMPLE WOUND • CIRCUMCISION OF INFANT • EVACUATION OF IMPACTED FEACES • CORRECTION OF SOME CASES OF POLYDACTYLY • DRAINAGE OF PARONYCHIA • OTHER PROCEDURES AS MAY BE LISTED FROM TIME TO TIME BY NHIS

  26. PRIMARY LEVEL INTERNAL MEDICINE • FEBRILE ILLNESSES • DIARRHOEAL DISEASES • UPPER RESPERATORY TRACT INFECTIONS • UNCOMPLICATED PNEUMONIA AND OTHER LUNG DISEASES • UNCOMPLICATED ASTHMA • ANAEMIA • HAEMOGLOBINOPATHIES • SKIN DISEASES • WORM INFESTATIONS • OTHER UNCOMPLICATED BACTERIA, FUNGAL, PLASTIC AND VIRAL INFECTIONS AND ILLNESSES • ROUTINE TREATMENT OF CHRONIC ILLNESSES E.G. HYPERTENSION, DIABETES ETC • LEPROSY • TUBERCULOSIS • DOG BITES • ARTHRITIS AND OTHER MUSCULOSKELETAL DISEASES • OTHER ILLNESSES AS MAY BE LISTED BY NHIS

  27. PRIMARY LEVEL PAEDIATRICS • IMMUNISATION • GROWTH MONITORING • FEEDING PROBLEM AND NUTRITIONAL SERVICES • TREATMENT OF COMMON ILLNESSES SUCH AS: - Febrile episodes - Diarrhoeal diseases - Uncomplicated malnutrition and failure to thrive - Measles and other childhood exanthemas - Viral illnesses - Skin diseases - Uncomplicated pneumonia - Upper respiratory tract infections • OTHER ILLNESSES AS MAY BE LISTED FROM TIME TO TIME BY NHIS

  28. PRIMARY LEVEL OBSTETRICS AND GYNAECOLOGY • ANTENATAL & POST NATAL CARE FOR 2ND 3RD 4TH PREGNANCES • POST NATAL • NORMAL DELIVERIES OF 2ND 3RD AND 4TH BABIES • UNCOMPLICATED PELVIC INFLAMMATORY DISEASE • MANUAL VACUUM ASPIRATION FOR INCOMPLETE ABORTION • OTHER ILLNESSES AS MAY BE LISTED FROM TIME TO TIME BY NHIS

  29. SONOGRAPHIC MEASUREMENTS • GESTATIONAL SAC DIAMETER.. GSD • GROWN-RUMP LENGTH…………CRL • BIPARIETAL DIAMETER…………BPD • OCCIPITOFRONTAL DIAMETER..OFD • HEAD CIRCUMFERENCE…………HC • ABDOMINAL DIAMETER…………AD • ABDOMINAL CIRCUMFERENCE…AC • FEMUR LENGTH……………………FL • GESTATIONAL AGE……………….GA • EXPECTED DATE OF DELIVERY..EDD • ESTIMATED FETAL WEIGHT…….EFW • SHEPHERD (AC, BPD) METHOD

  30. SECONDARY/TERTIARY LEVELS • HIGH RISK PREGNANCIES AND DELIVERIES • MULTIPLE GESTATION • CAESAREAN SECTIONS • ECTOPIC PREGNANCIES • SCREENING E.G. PAP SMEAR • OTHER OBSTETRICAL AND GYNAECOLOGICAL PROCEDURES

  31. PM schemes PM Silver (Basic): • General out patient consultation • Prescription Drugs • Basic Patient Care • Basic Laboratory Investigation • Minor Surgical procedures • Preventive Health and Counselling • Basic Hospital Accommodation and feeding • Health Promotion • Personal Accident/Insurance cover upto N50,000 PM Platinum: • General and Specialist Consultation • Prescription Drugs • Basic Patient Care • Comprehensive Laboratory Investigation • Basic X-ray/Ultrasound-(excluding MRI and CT Scan) • Minor, intermediate and major surgical procedures • Amenity Hospital Accommodation and Feeding • Normal Delivery (after 12 months of registration) • Gynaecological care -excluding infertility treatment • Immunisation and other Preventive Care • Basic Eye Care • Basic Dental Care • Health Status Screening • Personal Accident/Insurance cover upto N100,000

  32. PM Schemes PM Special (Enrollees only with special needs): • Amenity Ward plans • Plans for Retirement • International Health Coverage • Exercise Gymns • In-house or on site Health facilities PM Diamond: • General and Specialist Consultation • Prescribe drugs on formulary • Comprehensive Laboratory Investigation • Radiological, Ultrasound scanning and other relevant imaging procedure • In-patient care including feeding • Minor, intermediate and major surgical procedures • Antenatal Care • Normal Delivery including Caesarean operations • Eye Care • Dental Care • Annual Routine physical examination and health counselling

  33. PM GOLD • PM Gold Alpha • -         General and Specialist Consultation • -         Prescription Drugs • -         Basic Patient Care • -         Comprehensive Laboratory Investigation • -         Xray/Ultrasound – (excluding MRI and CT Scan) • -         Minor, intermediate and major surgical procedures • -         Amenity Hospital Accommodation • -         Normal delivery (after 12 months of registration) • -         Gynecological care – excluding infertility treatment. • -         Immunisation and other Preventive Care • -         Basic Eye care • -         Basic Dental Care • -         Annual Health Status Screening • -         Personal Accident Insurance cover up to N150,000

  34. COLLECTION AND DISBURSEMENT Analysis of Financial Requirements of NHIS Page 35 Operational Guidelines One Enrollee 2%Admin - 13.3% Premium 3% NHIS - 15% - 1%Reserve - 6.7% 12% - 6% - Capitation - 40% Primary health care 3% - Secondary health care Fee for Service - 20% 2% - Administration - 13.3% 1% - Reserve funds - 6.7% Resource package or Brokerage -(20%) - 1.34% Reserve Funds - Reserve deposit -(30%) - 2.01% 6.7% Profit – dividends -(50%) - 3.35% Shareholders

  35. MATERNAL MORTALITY IN SRI LANKA 1940 -1985 Maternal deaths per 100,000 livebirths WHO 99020

  36. OVERVIEW OF HEALTH CARE FINANCING IN NIGERIA (2) 37

  37. SERVICE STRUCTURE OF HEALTH INSTITUTIONS Funding Staff

  38. BURDEN OF DISEASES

  39. COMMUNITY BASED HEALTH INSURANCE SCHEME AS STRUCTURAL FOUNDATION RESEARCH TEACHING SERVICE

  40. PROGRESS TOWARDS ACHIEVING THE MDGS Eradicate extreme poverty and hunger 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 Ensure that boys and girls alike complete primary school Promote gender equality and empower women Eliminate gender disparity at all levels of education Reduce child mortality Reduce by two-thirds the under-five mortality ratio Improve maternal health Reduce by three-quarters the maternal mortality rate Combat HIV/AIDS, malaria and other diseases Halt and reverse the spread of HIV/AIDS Halt and reverse the spread of malaria and tuberculosis Ensure environmental sustainability 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

  41. Community Health Insurance Health of the People By the People and For the People.

  42. PREMIER MEDICAID WISHES YOU SOUND HEALTH THROUGH HEALTH INSURANCE • THANK YOU FOR THE ATTENTION • ……..PREMIER MEDICAID NIG. LTD.

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