THE PLACE OF MENTAL HEALTH IN NHIS PRESENTATION TO ASSOCIATION OF RESIDENT DOCTORS, NEURO-PSYCHIATRIC HOSPITAL, ABEOKUTA BY DR EMMA OHUAKANWA, MB;BS, MPA,

THE PLACE OF MENTAL HEALTH IN NHIS

PRESENTATION TO ASSOCIATION OF RESIDENT DOCTORS, NEURO-PSYCHIATRIC HOSPITAL,

ABEOKUTABY

DR EMMA OHUAKANWA, MB;BS, MPA, JP.31ST OCTOBER, 2007

SOCIAL HEALTH INSURANCE

• Based on the concept of social solidarity• A social security system that guarantees health

care services to participants • On payment of token contributions at regular

intervals • Contributions are paid into a common pool • Contributions based on ability to pay• Access to health care services based on need• Payment for health care services made from the

common pool

HISTORICAL PERSPECTIVE

• Bill for health insurance introduced in parliament in 1962

• Successive govts identified with it but lacked political will to commence it

• Documents modified over the years to suit peculiarity of the country

• NHIS finally established by Act 35 of 1999• Launched 6th June 2005 by President Olusegun

Obasanjo, after 43years• Access to health care by enrollees commenced

in September 2005

WHY HEALTH INSURANCE

• High mortality rates -Infant MR 100 for every 1,000 live births -Maternal MR 1,000 out of every 100,000 live births • 17% of women have no assistance during delivery• Live expectancy at birth 47• 201 out of every 1,000 children born die before they

reach age five

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THE NHIS

• NHIS is a body corporate with perpetual succession

• Established under Act 35, 1999,• To provide social health insurance in

Nigeria where health care services are paid for,

• From the common pool of funds contributed by the participants of the Scheme.

VISION

• A strong, dynamic and responsive National Health Insurance Scheme

• Totally committed to securing universal coverage and

• Access to adequate and affordable health care in order

• To improve the health status of Nigerians, especially for those participating in the various programmes/products of the Scheme.

MISSION

• To facilitate fair financing of health care 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 mechanisms prior to their falling ill.

• This is in addition to regulatory oversight of HMOs and HCPs

RATIONALE FOR NHIS

• The general poor state of the nation’s health care services

• Dwindling funding of the health care sector

• Increasing the financial resources for healthcare

RATIONALE FOR NHIS cont

• Poor integration of private health facilities in the nation’s health care delivery system

• Excessive dependence on govt health facilities

• Private huge spending (60%) on health services as out of pocket expenses

• Establishing patients’ rights as consumers

• Create demand for health care services

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 ensure efficiency and high standards in health care delivery services

OBJECTIVES OF NHIS cont

– 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 equitable distribution of health care costs among different income groups

– Ensure equitable patronage of all levels of healthcare. – To ensure availability of funds to the health sector

CORE FUNCTIONS

• Maintain and operate a health insurance fund.• Issue guidelines, set standards and regulate activities of

HCPs, HMOs and other health insurance actors• Mobilize additional resources to fund the health sector.• Define benefit packages and introduce health insurance

products.• Register HMOs and health care providers • Build capacity of health insurance operators .• Periodic actuarial analysis and determine capitation and

other payments

PROGRAMMES OF NHIS

• Formal sector progrmme

-Public sector (Federal, State, Local govts)

- Armed Forces, Police and other uniformed services

- Organized Private Sector

- Students in Tertiary institutions

- Voluntary participants

PROGRAMMES OF NHIS cont

• Informal Sector Programme - rural community - urban self employed• Vulnerable groups -permanently disabled people and aged - children under five - prison inmates• Others - international Travel health insurance - retirees and unemployed

Benefit Package

• Out-patient care, including necessary consumables;

• Prescribed drugs, pharmaceutical care as contained in the NHIS Essential Drugs List

• Diagnostic Test Lists; • Maternity care for up to four(4) live births

for every insured contributor/couple in the Formal Sector Programme;

Benefit Package contd

• Preventive care, including immunization, as it applies in the National Programme on Immunization, health education, family planning, antenatal and post-natal care;

• Eye examination and care, excluding the provision of spectacles and contact lenses


• Consultation with specialists, such as physicians pediatricians, obstetricians, gynaecologists, general surgeons, orthopaedic surgeons, ENT surgeons, dental surgeons, radiologists, psychiatrists, ophthalmologists, physiotherapists, etc


• Hospital care in a standard ward for a stay limited to cumulative 15 days per year. Thereafter, the beneficiary and/or the employer pays.

• A range of prostheses (limited to artificial limbs produced in Nigeria)


• Preventive dental care and pain relief (including consultation, dental health education, amalgam filling, and simple extraction).

• Note: All Providers are expected to provide counseling as an integral part of quality care.

EXCLUSIONS

Total Exclusion• Occupational/industrial injuries are excluded to the

extent covered under the Workmen Compensation Act.• High technology investigations, except in life-threatening

emergencies, e.g. C.T scan, MRI • Injuries resulting from: a. Natural disasters, e.g. earthquakes, landslides, etc (force majuer) b. Conflicts, social unrest, riots, wars, etc.• Domiciliary visits• Periodic medical check-up unrelated to illness

EXCLUSIONS contd

• Epidemics

• Family planning commodities, including condoms

• Injuries arising from extreme sports, e.g. car racing, horse racing, polo, mountaineering, boxing, wrestling, etc.

• Management of drug abuse/addiction

• Terminal illnesses, including all Cancers

EXCLUSIONS contd

• Surgery i. Transplant and cosmetic surgeries ii. High cost surgical procedure, including organ

transplants, e.g. open-heart surgery, neurosurgery (except Borehole), laminectomy etc

• Ophthalmology Provision of spectacles, contact lens, etc• ENT Hearing aids and associated appliances

EXCLUSIONS contd

• Medicine i. Management of CVA beyond the initial treatment ii. Tuberculosis iii. Chronic renal failure• Paediatrics i) Congenital abnormalities involving major/extensive surgical repairs, e.g. separation of Siamese twins, omphalocoele, etc. ii) Chronic congenital defects, e.g. Hirschsprung disease, etc.

EXCLUSIONS contd

• Obstetrics & Gynaecology Infertility management• Dental i. Dentures, crowns, bridges, implants ii. Scaling and polishing iii. Maxillo-facial surgeries iv. Root-canal treatment• Provision of meals on admission

EXCLUSIONS contd

Partial Exclusions• For life-saving emergency treatment requiring

high technology investigations, the HMO would pay 20% of the cost,

• Screening: Prostate Specific Antigen (PSA), PAP smear, Mammogram: the HMO would pay 20% of the cost

• However, in observance of any existing contractual agreement between employer and employee, the employer may choose to undertake extra cover in addition for its employees.

Categories of Healthcare Professionals under the NHIS

• General medical practitioners

• Specialist medical practitioners

• Pharmacists

• Lab scientists

• Physiotherapists

• Dental surgeons

• Community health workers

General Requirements for Health Care Providers (HCPs)

• Possession of the relevant academic qualifications in the field of endeavour;

• Registration with the relevant professional body;• Possession of the current license to practice;• Appropriate facility for service delivery;• Registration by state authorities (where

necessary);• Possession of malpractice insurance cover.

Requirements for General Medical Practitioners

• Possession of the Bachelor of Medicine, Bachelor of Surgery (MBBS) degree, or its equivalent, recognized by the Medical and Dental Council of Nigeria;• Registration with the Medical and Dental Council of Nigeria; Possession of the current licence to practise, issued by the Medical and Dental Council of Nigeria (MDCN).

Specialist Medical Practitioners

• physicians, paediatricians, psychiatrists,

• surgeons,dental surgeons, ENT surgeons,

• radiologists,

• gynaecologists,

• ophthalmologists, etc.

Requirement is possession of recognized specialist qualifications in the proposed area of practice

CLASSIFICATION OF HEALTH CARE PROVIDERS

Primary Health Care Providers - First contact with the enrollee, i.e. gatekeepers.• Primary Health Care Centers• Comprehensive health care centers• Nursing and maternity homes.• Out-patient departments of General Hospitals, Specialty Hospitals, Specialist Hospitals, Federal Medical Centers, Teaching Hospitals, Hospitals/Clinics of Armed Forces, Police and uniformed services, University Medical centers, Federal Staff

clinics/Hospitals.• v) Non-specialist private hospitals and clinics.

Secondary Health Care Providers

• Secondary Health Care Providers - (Fee-for-Service Providers) – provide health services on referral from Primary Providers

• General hospitals (out-patient specialist care and in-patient care for medical, surgical, paediatrics, obstetrics and gynaecology

etc),• Specialist hospitals• Federal medical centres• Pharmacies• Laboratories• Dental clinics• Physiotherapy clinics• Radiography centers, etc.

Tertiary Health Care Providers (Fee-for-Service)

• Tertiary Health Care Providers (Fee-for-Service Providers) provide health services on referral from primary and secondary levels.

These include :-• Teaching hospitals ;• Specialist hospitals,• Specialty/specialized hospitals (orthopedic,

psychiatric, etc),• Federal medical centres, and• Military reference hospitals.

FACILITY REQUIREMENTS FOR PRIMARY HCPs

• Waiting and Reception Area

• Consulting Room

• Treatment Room

• Patients’ toilet facilities with adequate water supply

• Sterilizer/Autoclave

• Emergency tray

FACILITY REQUIREMENTS FOR PRIMARY HCPs contd

• Appropriate fire fighting equipment

• Adequate waste disposal facilities.

• Containers for disposal of sharp objects

• Refrigerator

Personnel Requirements

• Primary Healthcare centers meet the standards set by the National Primary Health Care Development Agency (NPHCDA),

• Other primary HCPs should have the following:• At least one medical practitioner• At least two registered nurses/Midwives• At least two hospital assistants• At least one administrative staff for medical

records and secretarial duties

REQUIREMENTS FOR SECONDARY and TERTIARY

HCPs

• Out-patient and in-patient services for medical, surgical, paediatric, maternal care, etc.

• The minimum requirements for a tertiary hospital is as in a secondary healthcare centre, but with the additional requirement that each specialty be fully devoted to the specialty

ACTIONS AND PROCEDURES AT EACH LEVEL OF CARE

• These are listed in the Operational Guidelines• Includes mental health cases at all the levels of

care. • Enrollees in the NHIS are entitled to

hospitalization in general wards only, with the exclusion of meals.

• However, the use of amenity/private wards and feeding will attract extra charges to the enrollee at the point of use.

REFERRALS

• Actions and procedures at each level listed in guideline• Primary HCP is first port of call for enrollee ie gate

keeper• Cases that require specialist attention or investigation

are referred • Referrals are to ensure cost-effectiveness and efficiency

in patients’ management under the NHIS.• Referral is from Primary to Secondary or Tertiary

provider• Approval by the HMOs is necessary, except in

emergencies• Notification of such emergencies should be served within

48hrs.

REFERRALS contd

• Referrals should be to the nearest accredited secondary or tertiary HCP.

• The condition must be covered in the benefit package

• Condition not covered by capitation• Referral letter must accompany every case.• Personal and medical details must be contained

in the referral letter.• All investigations carried out at a lower level

must be sent to the higher level.

REFERRALS contd

• The outcome of a referral should be properly documented.

• Referred cases must be sent back by the specialist after completion of treatment to the referring provider, with a report and instructions for follow-up management

REFERRALS contd

Information Required for Referral• Patient’s name, gender, age and address• Referral location (dept/clinic)• Patient’s hospital number• Patient HMO and NHIS number• Referring Provider’s NHIS registration number• Referral date• Clinical findings/investigations and results• Provisional diagnosis• Reasons for referral• Referring personnel’s name and signature

PROCEDURE FOR THE ACCREDITATION OF HCPs

• All health care Providers are to be accredited by the NHIS as a prerequisite for participation in the Scheme.

• Providers are to obtain the necessary documents stipulating the minimum requirements for accreditation.

• The NHIS may accredit Providers only after inspection.• Accreditation fee is N10,000.00 Five Thousand Naira• Renewal fee N5,000.00. The fees are subject to review.

PROCEDURE FOR THE ACCREDITATION OF HCPs cont

• Obligations of the Provider shall include:• Providing the NHIS with the following information:- - i) Names of serving health professionals and their

qualifications (doctors, nurses, pharmacists, etc); - ii) Work hours; - iii) Details of equipment available for medical care; - iv) Ensuring every beneficiary who visits facility is

attended to with utmost care, skill and prompt attention; • Adopt operational techniques that shall protect patients’

confidentiality.

OBLIGATIONS OF HCPs

• All accredited Health Care Providers enter into agreement with the HMOs for two years in the first instance, subject to renewal.

• Agreement between Provider and HMO shall include the following terms:

• Acceptance by the Provider to provide healthcare services, 24 hours a day and 365 days in the year;• Accepting beneficiaries without discrimination; cannot

reject patient except on appeal to NHIS stating grounds for rejection; this shall be only after three months of initial registration with the provider;

• Stock generic drugs based on the National Essential Drugs List;

OBLIGATIONS OF HCPs

• All beneficiaries shall be given adequate treatment;

• A Provider shall not see a beneficiary as a private

patient;• Sending patients only to the NHIS-accredited specialists’ facility; • Using only the approved referral line. • Either party to the agreement shall have the right

to terminate the agreement by giving 3 months notice in writing from the day of receipt of notice.

OBLIGATIONS OF HMOs

• The obligations of the HMOs shall include payment of

• capitation for primary health care providers and fee-for-service for secondary and tertiary HCPs.

• The NHIS shall regulate all the fees payable. • The HMOs shall: i) Ensure continuous monitoring of the

Providers. ii) The Providers should allow HMOs easy

access for such monitoring.

PAYMENT OF HCPs

• Capitation – 550 per enrollee per month– Actuarilly determined– Paid 14 days before beginning of covered month

• FFS– Fee schedule/price list– Claims to be submitted monthly to HMO within 14

days– Claims for settlement by HMO within 14 days of

receipt after verification– Patient makes co-payment for drugs

MALPRACTICE INSURANCE

• A professional indemnity insurance • against the risk of professional malpractice • a participant believes he/she has suffered injury • proceeds to court to seek redress, as a result of

which compensation is awarded to the participant.

• claims for damages, breach of professional duty, negligent act, error or omission by the HCP

• Insurance Company accredited by the Scheme

MENTAL HEALTH

• Mental health adequately covered as listed in Guidelines

• Minor psychiatric services covered at primary level

• Major psychiatric problems covered at secondary/tertiary level care

• Psychotherapeutic drugs listed in NHIS drug list

THANK YOU

FOR LISTENING