Making Quality Healthcare Affordable to Low Income Groups

Making Quality Healthcare Affordable to Low Income Groups

Presentation by Mrs. Njide NdiliManaging Director, Hygeia Community Health Plan

January 12th 2009

OUTLINE

Overview of Healthcare Financing Issues in Nigeria The Hygeia Community Health Plan Model How the Scheme Works

Enrolment Utilization Provider Management Upgrade Data Management

Stewardship & Advocacy for Scale Up and Sustainability

THE NIGERIAN HEALTH SYSTEM The health care system in

Nigeria was ranked 187 out of 191 countries

The healthcare sector has been under-developed because of resource constraints, with total per capita expenditure being about $22 (N2800).

75% of this healthcare expenditure is out-of-pocket

Government expenditure is currently about 6% of total Government Expenditure & less than 3% of GDP

HEALTHCARE FINANCING REGULATORY ISSUES

Necessary to seek alternative sources of financing and access to health care, shifting to demand-based and output driven schemes

Led to growth of Risk Pools, starting with formal sector (public and private workers), directed by regulatory body (National Health Insurance Scheme) and administered by Private Sector HMOs

Resulted in significantly increased access to modern healthcare services - 3 million people presently covered nationwide

However approx. 70% of Nigeria’s population outside formal sector, i.e. most of informal sector and rural communities cannot afford to pay for health insurance

4

Rural Communities

Formal Sector

Informal Sector

70% of Population

require subsidy

Public Sector

Organized Private Sector

POPULATION STRATIFICATION FOR RISK POOLING

TOWARDS UNIVERSAL COVERAGE Nigeria aims to achieve universal coverage by 2015

Achieving universal coverage must commence with a focus on the community

This aids to foster pre-payment and risk pooling in preparation for a more comprehensive national system

Focus on Healthcare quality improvement through a management and monitoring system will guide the growth of resources towards universal coverage

Leveraging financial resources from all stakeholders including public, private and donor programmes is key

This has been achieve in several states and countries over several years:

6

COUNTRY DURATION

Germany 127 years

Japan 36 years

Costa Rica 20 years

COUNTRY DURATION

Rwanda (85%) 9 Years

Ghana (50%) 4 Years

Andhra Pradesh, India (630,000 lives)

1 Year

THE SPONSORS

• Foundation: Health Insurance Fund• Chairman of the Board: Kees Storm (Aegon,

KLM)

• NGO with a focus on scale up of HIV/AIDs care and treatment across Africa

Dutch Government

Dutch Government

Donors• Founding donor: Dutch Ministry of Foreign

Affairs; other Dutch companies eg Shell, Unilever• Initial grant of €100m for 6 years / 4 countries

• Implementing partner in Nigeria• Incorporated Hygeia Community Health Plan to

focus on day to day activities

ConnectConnect

THE HCHP MODEL IN PARTNERSHIP WITH

DEMAND:Healthcare membershipMedical care usage

Subsidy injection

•Introduce a financing system and subsidise membership to stimulate demand

•Healthcare revenues are guaranteed, meaning investments can be made in healthcare quality

•Higher quality of services further fuels demand

SUPPLY:Quality healthcare

delivery

finan

cing

financing

Collective healthcare financing system including:

• Pre-payment• Risk pooling

HYGEIA COMMUNITY HEALTH PLAN (HCHP) Provides access for low income communities to quality basic health

care services through a donor subsidized demand-driven health insurance scheme

Commenced operations in January, 2007

With pilot schemes in Kwara State (focused on Shonga and its environs) and Lagos State (focused on market women and Lady Mechanic)

Currently has over 50,000 Individuals enrolled, out of which over 32, 000 are in Kwara State and 18,000 in Lagos

Provider Network includes 13 private and 6 public hospitals in both Kwara State and Lagos Sate

The draft NHIS Blueprint for Community-based Health Insurance is very much in line with our model and we are proud to have kick-started the discussion leading to the current roll-out of NHIS-MDG Maternal & Child Health Risk Pooling Scheme in 6 selected states

9

10

FOUR PILLAR APPROACH TO CHIS

QUALITY SYSTEMS

MANAGED CARE

PLATFORM

EDUCATION AND

AWARENESS

FINANCING THE

SUBSIDY

PROVIDER SYSTEMS

COMMUNITY ADMINISTRATION

MANAGED CARE PLATFORM

• The Scheme is built on the platform of the HMO managed care system which integrates the financing, management and delivery of defined health care services to a designated population through a network of providers.

• The HMO is further responsible for ensuring the quality of health care services and has a responsibility to educate the beneficiaries and the providers about the scheme and pertinent health care issues.

11

Risk of Care (Actuarial)

Pricing of Care

Cost of Care

Quality of Care

Provision of

uninterr-upted care

Performance of

provider and

referral system

Deliveryof

Care

Financing Management DeliveryPHC

FINANCING THE SUBSIDY

• Objective is to generate sufficient and sustainable resources for the provision of comprehensive primary health care services through community health insurance.

• Financing the required subsidy can be derived from: Public Budgetary Allocation General taxes Special taxes Donor funding Corporate social responsibility funds Individual contributions – co premiums A combination of above listed

12

PROVIDER SYSTEMS A network of primary care and referral centres is developed to

provide comprehensive health care services to the enrolled population.

Primary health centres serve as gate keeper and are responsible for health promotion, preventive and curative activities.

Selection is based on specific criteria including

• Proximity to the target communities

• Attainment of minimum standards of quality

• Ability to demonstrate willingness to implement recommended quality Improvement plan

• Appropriate Benefit Package based on the Primary Healthcare Delivery Platform based on:

• Existing NHIS Benefit Package

• Specific Disease Intervention (eg. HIV/AIDS)

• Community Requirements (eg. Cataract Surgery) 13

QUALITY IMPROVEMENT

• Ensures that all stakeholders derive value from the scheme

• Quality improvement involves: Provider Infrastructure and equipment upgrade Capacity building Standardization of treatment pathways using protocols Utilization Data Collection and Analysis Ongoing monitoring and evaluation

14

EDUCATION AND AWARENESS The community needs to be empowered by putting knowledge

directly in their hands through education and communication focused on: Risk Pooling for Health Insurance

Personal health care and health status

How to enroll in the scheme and to make appropriate use of the facilities

Channels of communication through the BOT to ensure feedback loop from the enrollees

Community Mobilization must not be under-estimated and all strategies must be employed such as:

– Marketing activities include Media Campaign using of T.V, Radio and print media

– Sensitization and awareness of target groups, Provider involvement, Give-aways& Competitions, Market Storms

15

SENSITIZATION, CO-PREMIUM COLLECTION AND ENROLMENT IN A LAGOS MARKET

CO-PREMIUM COLLECTION AND ENROLMENT IN SHONGA VILLAGE, KWARA

ENROLING THE EMIR OF SHONGA

CUMULATIVE ENROLLMENT JAN ’07 – DEC. ‘08

19Enrollment continues to grow steadily with over 50,000 people currently enrolled in both States

05000

10000

15000

20000

25000

30000

3500040000

45000

50000

Feb'07

May'07

Aug'07

Nov'07

Feb'08

May'08

Aug'08

Nov'08

kwara lagos

Malaria outreach exercises including health education, environmental sanitation, distribution of insecticide treated nets (ITN)

HIV voluntary counseling and testing

Hypertension and diabetes screening programmes

Free routine check up including Visual screening and Breast examination

Focus on Maternal Mortality by encouraging pregnant women to attend at least 4 sessions of Ante-Natal care

FOCUS ON PREVENTIVE CARE

HEALTH PROMOTION – HIV/AIDS OUTREACH PROGRAMMES

VCT is carried out during the outreach programmes and in the provider locations in Kwara and Lagos State

HEALTH PROMOTION – ROLL BACK MALARIA; DISTRIBUTION OF ITNS

Distribution of Insecticide Treated Nets in Kwara Communities and Lagos Markets during Malaria Outreach Programmes

ADVOCACY FOR SANITATION AND WATER SUPPLY

Advocacy for sanitation (Clearing of a refuse dump at Shonga community)

Encouraging and setting the example for clean environment and safe water supply in rural communities

PREVENTIVE CARE -FREE HEALTH CHECKS

Free check up and screening for Hypertension, Diabetes, HIV/AIDS and Visual acuity

CURATIVE SERVICES

26

PMTCT AND MATERNAL CARE TESTIMONIALS

HIV negative baby born to

HIV positive parentsMother and baby “Hygeia” doing well

after obstructed labour during child birth

EQUIPMENT & INFRASTRUCTURE UPGRADE

Equipment Upgrade:

• Providers have been supplied essential clinical equipment under the Year 1 upgrade plans with 3 year target for achieving Quality Improvement Criteria

• Over $600,000 worth of equipments have been donated to the participating providers

Infrastructure Upgrade:

• Kwara State Government contributed more than $130,000 for the upgrade of the Shonga PHC

• All scheduled works have been completed but further upgrades planned in Year 3

These upgrades have complemented other HCHP quality improvement initiatives resulting in

improved provider services and patient care

PROVIDER TRAINING PROGRAMMES• Training programmes held quarterly in 2007 & 2008

• Trainers selected from PharmAccess, Lagoon hospitals, UITH, LUTH and LASUTH

• Year 1 (2007) focused on Scheme Management, Maternal care, HIV/AIDS care, Infant and Child care & Malaria in infants

• Year 2 (2008) focused on Malaria, Hypertension, Diabetes and Quality Management

• 2009 programmes to target health related MDGs including:– Malaria– Obstetric emergencies

PROVIDER TRAINING PROGRAMMES

Provider staff are trained quarterly on management of common ailments, current trends in patient care and management

PROVIDER M&E

• Bi-annual Monitoring & Evaluation surveys are conducted by PharmAccess International to monitor the improvement of quality of service delivered by the providers and to identify priorities for further improvements.

• The report of each M&E visit is used to guide further quality improvement and design of upgrade plans.

• Scoring is benchmarked among the facilities to encourage “constructive competition”

30

PROVIDER QUALITY IMPROVEMENT

Quality improvement since the start of the program

44%41%

44%40% 40% 40% 41%

37% 36%39% 37%

33%

49%

42% 41% 41% 42% 42% 41%38% 36% 36% 35%

31%

65%

56%53%

42%47% 46%

56%

46%

40%

29%

37%

45%

33%

41%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

LagoonClinic VI

May Clinics R-JoladHospital

Orile AgegeGeneralHospital

CrystalSpecialistHospital

Suru-LereGeneralHospital

OshuntuyiMedicalCenter

Topaz Clinic HealsSpecialist

Clinic

SalvationArmy Clinic

Ola-OluHospital

Ogo-OluwaHospital

ResourceAccess Unit

ShongaCommunity

HealthCentre

0-measurement

1-measurement

2-measurement

The M&E reviews have demonstrated improvement in the performance of the providers since the inception of the scheme

A B C D E F G H I J K L M N

DATA MANAGEMENT Encounter data gathered through monthly utilization reports

which the providers are contractually bound to provide

Computers and internet facilities have been installed in each hospital to facilitate real time data capture and access to medical resources on the internet

The availability and management of monthly encounter data enables real-time decisions to be made based on the current state of affairs in the target communities as witnessed at the providers

The scheme managers are therefore able to make better informed decisions in terms of what upgrade is required and targeted public health response to evident burden of disease patterns

32

33

UTILIZATION–POST SCHEME COMMENCEMENT

• The enrollees appreciate and are utilizing the scheme

• Over 110,000 encounters since start of scheme in both states

• Current average of over 5000 encounters per month in Lagos and 4,000 in Kwara eg Shonga PHC alone had an average of 16 encounters before commencement of the Scheme and now has encounters of over 3000 every month

PROMINENT DIAGNOSIS

34

Malaria continues to be the most prevalent diagnosis and also draw attention to prevalence of non-communicable diseases

TOP 10 INVESTIGATIONS

35Malaria parasite check continues to be the most prevalent investigation

TOP 10 THERAPIES IN 2008 vs 2007

36

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

2007

2008

Increase in the prescription of Artesunate and decrease in prescription of Chloroquine

STEWARDSHIP & ADVOCACY FOR

SCALE-UP & SUSTAINABILITY

COMMUNITY PARTICIPATION Community participation is a cardinal principle of the Primary

Health Care Concept.

The support of the community leaders is critical to the success of the scheme in any community.

Cultural, religious and political leaders are identified and educated about the benefits of the scheme. The buy-in of these leaders facilitates the subsequent acceptance of the scheme by the entire community.

HRH Emir of Shonga has been intensely engaged in the operation of the scheme in the community, as Chairman of the Board of Trustees, and has been an invaluable asset in achieving the buy-in of the community.

38

39

COMMUNITY PARTICIPATION – SHONGA BOT

CONFERENCE ON COMMUNITY HEALTH INSURANCE IN AFRICA ORGANISED BY HYGEIA

• Held May 8th 2008 in Abuja

• Opened by HE Kwara Governor Bukola Saraki

• Other Speakers: HE Mr. Arie Van der Wiel, the Dutch Ambassador to Nigeria and Prof. E.A Elebute, Chairman Hygeia

• Field trip to pilot community in Shonga, Kwara State for 30 participants

• Presentation to Nigerian Governors’ Forum Retreat in October 2007; seven additional states have expressed keen interest

• Presentation made to DG of WHO, Dr Margaret Chan on visit to Nigeria in February 2008

• Dr Chan supportive of “Shonga model” as exemplary primary health care delivery system in Africa

• “Shonga model” presented and well received at the OECD Innovative Financing Conference in Healthcare meeting on October 7, 2008 in Paris

• The new Minister of Health, Dr. Babatunde Osotimehin visited Shonga on January 7th 2009 to witness and understand the model and how it can be scaled up across the nation.

LOCAL & INTERNATIONAL ADVOCACY

• The World bank has approved funds to subsidize insurance premiums for CAPDAN (ICT village) in Ikeja, Lagos with a target enrollee base of 30,000. The scheme is scheduled to commence by April 2009.

• The HIF has committed funding towards the scale-up of the scheme in Kwara State to the Afon community with a target enrollee based of 71,000 people. The scheme is scheduled to commence in April 2009

• HCHP is also working with Shell to develop a similar programme for the IA cluster communities in Port Harcourt, Rivers State with the Obio facility upgraded by Shell as the focal provider

SCHEME SCALE-UP

ENDING NOTES HCHP through its demand-side interventions, has led to a re-vitalized

approach to healthcare delivery, with the ability to provide the following:

Strengthening of the Health System base in the Community

Provision of a framework to leverage resources from and mainstream vertical Programmes such as Malaria, HIV/AIDS, Maternal Health & Child Immunization

Catalyst to improving healthcare indicators of the wide population base of the rural and urban poor, thereby contributing significantly to achieving the Millennium Development Goals.

Positive example of Public-Private Partnership through the implementation achievements with Hygeia, its private sector partner

HCHP look forward to partnering with government agencies, developmental and corporate organizations and foundations and other key stakeholders to achieve the mission of “taking healthcare to the people of Nigeria”

43

THANK YOU!