Community Based Health Insurance: A tool for Achieving MDGs 4 & 5 By Dr Abdulrahaman Sambo mni Acting Executive Secretary, NHIS At The Conference of Association.

Community Based Health Insurance: A tool for Achieving MDGs 4 & 5

By

Dr Abdulrahaman Sambo mniActing Executive Secretary, NHIS

AtThe Conference of Association of General Practice Nursing Practitioners of Nigeria

(AGPNP).

On19th July, 2012 at the Ikeja Airport Hotel Lagos.

PREAMBLE

• Nigeria’s health system is still poorly rated.

• Nigeria was ranked low in 2005 (197th out of 200 member nations)

• Reported life expectancy of 48years for males and 50years for females

• Healthy Life expectancy (HALE) for both sexes is put at 42years

Source : WHO 2009

HEALTHY LIFE EXPECTANCY (HALE)

• HALE adjusts life expectancy for healthy life without disability, and is a more objective measure of survival

• In HALE estimation, Nigeria only ranked higher than 5 countries(Sierra Leone, Afghanistan, Zimbabwe, Zambia and Lesotho).

• Analysis showed that the low HALE ranking of Nigeria was due to the high maternal, neonatal, infant and under-five mortality.

Source: WHO 2009

OBJECTIVES OF THIS PRESENTATION

• To present current statistics relating to maternal and child mortality in Nigeria

• To identify some of the most important determinants of maternal and child mortality in Nigeria

• To look at Community Based health insurance and how it can be a tool for achieving MDGs 4 & 5

MATERNAL AND CHILD HEALTH IN NIGERIA: SITUATION ANALYSIS

• Nigeria accounts for 10% of global maternal mortality figure

• 59,000 women die annually from pregnancy and child birth

• For every maternal death, 30 others suffer long term disabilities

• 40% (about 800,000) of global obstetric fistulas occur in Nigeria

Source: WHO

MATERNAL AND CHILD HEALTH IN NIGERIA: SITUATION ANALYSIS (CONTD.)

• 58% of pregnant women have full ANC coverage*

• Only 39% of births delivered by skilled health professional*

• Risk of a woman dying from child birth is 1 in 18 in Nigeria compared to 1 in 61 for all developing countries and 1 in 800 in developed countries**

• Only 23% of children (12- 23months) received full course of immunization against childhood killer diseases*.

Source: *NDHS 2008 ** WHO 2005.

MDG 4 & 5: TARGETS

• MDG 4: Reduce child mortality by two thirds by 2015

• Target: Reduce U5mortality by two thirds between 2000 &

2015 (From 207 in 2000 to 67 by 2015)

• Target decline rate to achieve MDG 4 by 2015 in Nigeria was

6.7% per annum (9.3/1,000 live births)

• MDG 5: Improve maternal Health • Target: Reduce by ¾ maternal mortality between 1990& 2015

(From 704 in 2000 to about 176 by 2015)

• Target decline rate to achieve MDG 5 by 2015 in Nigeria was

6.7% per annum (35.2/100,000 live births per year)

PROGESS TOWARDS ACHIEVING MDGs 4 & 5

• NDHS(2008) puts U5 Mortality at 157/1000 live births• Thus U5 Mortality decreasing slowly (rate of 4.5% per annum)• Infant Mortality of 75/1000 live births• Based on current statistics, 14.4% annual reduction (12.9/1000 births

per annum) required from 2009 to achieve target set in 2000 ( i.e. <67/1000 births )for MDG 4 by 2015

• Maternal mortality has decreased in Nigeria• Current figure is 545/100,000 live births, • Decrease of about 22.7% since 2000• Decreasing at rate of 1.9%/annum (133/100,000 live births per annum )• To achieve the 2000 target for MDG 5, a decrease of about 14.2%

/annum (132/100,000 live births) is required from 2009 - 2015.

Data source: NDHS (2008).

CAUSES OF POOR MATERNAL AND CHILD HEALTH OUTCOME

• Physical and financial barriers to access to healthcare leading to;

• Delay in decision to seek care• Delay in reaching health care facility• Delay in getting healthcare

• Poor funding of the health system

• Weak national health infrastructure• Inequitable distribution of facilities against rural

areas• Health facilities unable to deliver minimum level of

care• Mal-distribution of human resources for health

favouring the urban centres

Measuring success – Indicators to MDG 5

• Contraceptive prevalence rate • Adolescent birth rate • Antenatal care coverage (at least one visit and at

least four visits)• Unmet need for family planning

Measuring success – Indicators to MDG 4

• Under-five mortality rate• Infant mortality rate• Proportion of 1-year-old children immunized

against measles.

CBHI as a concept

CBHI is a non-profit Health Insurance Programme for a cohesive group of households/individuals or occupation based groups, formed on the basis of the ethics of mutual aid and the collective pooling of health risks, in which members take part in its management

Objectives

• To serve as a mechanism for mobilizing community resources in the financing of health services for members;

• To improve access to health care services for community members, including pregnant women & CU5.

• To improve the quality of healthcare by increasing both the amount and reliability of resources available for providers;

• To improve efficiency in the allocation and use of available financial resources.;

• To make health services more equitable.

CBHI Implementation in Nigeria – Progress so far

14

• Developed the blueprint for implementing CBHIs in Nigeria.

• Extensive review of literature on Community Health Financing.

• Study tours to learn lessons and international/national best practices

• Piloted CBHI schemes across the country• Presidential launch of CBHI in Dec 2011• Roadmap for 3- year pilot phase developed

Lessons Learnt from Initial Pilots

15

• Weak technical & administrative capacity of BOTs• Community ownership and participation in CBHI is

key to sustainability,• Fragmentation of CBHF as small does not allow for

significant pooling of health risks/costs and enhanced equity.

• Government support is key to successful implementation of CBHI

• Provision of targeted subsidy important for wider coverage and sustainability of CBHI schemes.

• CSOs and NGOs could play a significant role in the promotion and management of CBHI,

Management Models for CBHI

16

• Board of Trustees (BoTs) as Programme Managers without Technical Facilitators

• BoTs as Programme Managers with Technical Facilitators (cHMOs/CSOs)

• Technical Facilitators (cHMOs/CSOs) as Programme Managers

Management Model 1

17

• Board of Trustees (BoTs) as Programme Managers without Technical Facilitators Programme owned by community members and

managed by representatives (BoTs) BoTs have sufficient technical & administrative

capacity to manage programmeor

BoTs have not been privileged/cannot afford to engage a technical facilitator

Existing community structures (Village/ward development committees, CSOs, etc) provide platform for programme take off

CBHIP Management Model 1

18

• Strengths Community ownership & management promote

sustainability Comparatively low programme administrative cost Ease of local resource collection and pooling

• Weaknesses Small resource pool Limited population and service coverage Weak technical capacity of programme managers Overlap of responsibilities and stretching of members

CBHIP Management Model 2

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• BoTs as Programme Managers with Technical Facilitators (cHMOs/CSOs) Recognize inherent weakness in the technical

capacity of BoTs to effectively manage programme

Engage NHIS accredited technical facilitator to provide programme support

Community members maintain programme ownership and co-management with TFs

Only technical functions are performed by TFs Non technical day-to-day administrative activities

are performed by TFs

CBHIP Management Model 2

20

• Strengths Enhanced technical competence in programme

management Reduced workload on BoTs resulting in improved

performance Improved negotiation with providers resulting in lower cost Improved capacity for medical audit and quality assurance

which translate to improved quality of service Ability to form robust pools by bringing together small

multiple pools

• Weakness Increased programme cost due to TF hire Possible role conflict between TFs and BoTs

CBHI Management Model 3

21

• Technical Facilitators (cHMOs/CSOs) as Programme Managers Programme ownership vested with the community

members BOTs relinquish all aspects of programme

management/administration to the TFs

CBHI Management Model 3

22

• Strengths Clear split between ownership & management leading to

improved performance Enhanced technical competence in programme management Reduced workload on BoTs resulting in improved performance Improved negotiation with providers resulting in lower cost Improved capacity for medical audit and quality assurance

which translate to improved quality of service Ability to form robust pools by bringing together small

multiple pools

• Weakness Increased programme cost due to TF hire Possible role conflict between TFs and BoTs For-Profit Agenda of TFs

Key Stakeholders

• Community Members• Programme Managers - Board of Trustees

(BoT) and Technical facilitators (TFs)• Technical Facilitators (cHMOs, NGOs, CBOs,

FBOs and limited liability companies, or companies limited by guaranty.)

• Healthcare Providers• Organized Private Sector• Development Partners • Governments (LGA, State & Federal)• NHIS

NHIS

• Regulate the practice of CBSHIP including the development and periodic review (based on lessons learnt) of strategies to promote CBSHI Programmes.

• Support TFs in Actuarial reviews for contribution rates and payment to HCPs

•  Capacity building of Technical Facilitators and Programme Managers.

• Collaborate with other key stakeholders to generate financial support for subsidy.

• Develop IEC strategies for the purpose of generating awareness on CBSHIPs.

•  Provide high level advocacy to generate support from policy makers at the different levels of government.

•  Contribute to the establishment and management of the CHISNEF.

Roles of Technical Facilitators

• Generate primary and secondary data (surveys, etc) for the purpose of programme design and monitoring,

• Determine benefit package and contribution rates in consultation with community members,

• Conduct medical auditing and quality assurance,• Conduct capacity building activities for the BOTs

and participating healthcare providers• Supervise and monitor Programme activities,• Assist new participating communities to set up

Board of Trustees (BOTs),• Send regular reports/feedback to the NHIS,

communities & providers

Role of BOTs

• Conduct mobilization & sensitization of community members,• Register and regularly update the record of members,,• Collect contribution from participating members and keep

record of same,• Pay contributions collected to TFs (in TF- managed

programmes) • Pay Healthcare Providers in BOT-managed programmes.• Screen members to benefit from subsidy financing.• Support health promotion and prevention activities.• Provide community level quality assurance.• Organize regular community meetings (for feedback).• Send regular reports/feedback to community members,

providers and TFs where applicable.

Roles of HCPs

• Sign contractual agreement with Programme managers,

• Provide quality services to registered members,

• Maintain all records of services given and payments received,

• Provide health prevention and promotion services,

• Provide regular feedback to Programme managers.

Operation of CBHI

• Community members form a Mutual health Association (MHA).

• The MHA elects a Board of Trustees (BOT).• Members determine the benefit coverage.• Actuarial costing of benefit package done to

determine premium payable.• Members pay determined premium.• A health facility is chosen to provide health

services.• A gatekeeper is appointed to control service

utilization to control moral hazards.

Funding MCH care under CBHI

• NHIS• National Health Bill• Proposed Vulnerable Groups Fund

Proposed telecoms tax Proposed sin tax

Other Sources

Strength of CBHI

• Outreach penetration achieved through community participation

• An instrument for social cohesion.• Contribution to financial protection against illness.• Increase in access to healthcare for community

members.• Can be an avenue for required community

mobilization for action to achieve MDGs 4 & 5 targets.

• Can provide an avenue for financing the health care needs of pregnant women and CU5.

Weaknesses

• Low levels of revenues that can be mobilized• Frequent exclusion of the poorest of the poor and

vulnerable groups including pregnant women and CU5.

• Small size of risk pools• Limited management capacities

CBHI & Achieving MDG 4 &5

• CBHI can be an instrument to improve access to

care for pregnant women and CU5.• Can provide financial protection to households

against the ill health that lea to poor maternal & Child health.

• An effective mechanism for subsidy targeting of pregnant women and children under five (CU5).

• Evidence from Rwanda shows that CBHI can be a strong tool for achieving MDGs 4 &5.

• The NHIS/MDG – MCH project is a case in point.

Enhancing CBHI Capacity

• Pooling at higher levels rather than community level to improve pool size and increase equity.

• Improve technical and managerial capacities of BOTs to run MHAs.

• Target subsidy from government for vulnerable groups such as pregnant women and CU5.

Conclusion

• CBHI can effectively contribute to achieving MDGs 4 & 5.

• This can be a good vehicle for appropriate intervention by concerned stakeholders.

• Government has very important roles to play to widen coverage with CBHI and improve access to care by pregnant women and CU5.

Thank you