Insights From The Leading HMO's On The Nigerian Health Industry by BusinessDay

ÂŠ BRIU, 2018 6, Point Road, G.R.A., Apapa, Lagos www.businessdayonline.com email: research@businessdayonline.com

This document has been prepared in good faith on the basis of information available at the date of publication. BusinessDay Research & Intelligence Unit (BRIU) does not warrant the accuracy, reliability or completeness of the information in this report for the purpose of making any investment decision. Readers are advised to assess the relevance and accuracy of the content of this publication against the limitations noted herein. BRIU will not be liable for any loss, damage, cost or expense incurred or arising by reason of any person using or relying on information in this publication. The opinions/conclusions and suggestions in this report do not represent investment or other advice and should therefore not be construed as such.

This publication is a copyright. Apart from any use as permitted under Copyright Act 1968, Nigeria, no part contained herein may be reproduced, copied or duplicated in any form without prior written consent of BRIU.

This report is prepared by:

Omosomi Omomia Tel: +234 809 482 1958 Email: omosomi.omomia@businessdayonline.com

Aderemi Ayeni Tel: +234 703 435 2828 Email: aderemi.ayeni@businessdayonline.com

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA ON THE NIGERIAN HEALTH INSURANCE INDUSTRY EXCLUSIVE BRIEF

OMOSOMI OMOMIA

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

BusinessDay Research and Intelligence is a unit of BusinessDay Media Limited, specialising in the gathering and analysis of economic and financial data as well as forward-looking intelligence on Nigeria and West Africa. We have a complete database and valuation of all Nigeria-listed firms, with the aim of expanding it to include listed companies in West Africa over the next 12 months. We provide in-depth analysis of different sectors of the Nigeria and West African economy, drawing extensively from our network of industry contacts to provide insights which are not publicly available. We are committed to the dissemination of reliable, credible, timely and relevant information to both private and public sector decision-makers.

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

Contents 8 Forward 10 Objectives

Chapter 1 Overview of the Health Insurance Industry in Nigeria

Chapter 2 The Health Insurance Market in Nigeria: The Way Forward

Chapter 3 Improving Nigeria’s Health Insurance Coverage: Industry Perspectives and Recommendations.

Chapter 4 31 Profiles of the leading Health Maintenance Organisations in Nigeria

Chapter 5 Avon HMO: Five Years of Setting the Bar in Nigeria’s HMO Industry and Next Steps

Chapter 6 43 Healthcare International Re-Positions For Better Service Delivery

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

Chapter 7 ‘I envision a more consolidated industry with fewer but tried, trusted and stronger players...

Chapter 8 ‘Without a new law, there would be a bitter struggle by operators to capture less than 4% of the population enrolled.’

Chapter 9 ‘Most Nigerians are not aware and do not understand or appreciate the need for health insurance.’

Chapter 10 How Avon HMO is Driving Healthcare Inclusion in Retail Sector

Chapter 11 67 Nigerian Health Insurance Scheme: Issues, Prospects and Potential

Chapter 12 Policy Context of The Health Sector

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

Forward Omosomi Omomia

BusinessDay presents insights from the Leading HMOs in Nigeria. These HMOs have contributed significantly to policy advocacy, regulatory framework, healthcare delivery and the development of the nation’s health insurance market. The five HMOs are Avon HMO Limited, AIICO Multishield, Healthcare International, Hygeia Nigeria and Total Health Trust (THT). The Report contains interviews with these major players on the issues, challenges, trends, and outlook for the Healthcare and Health Insurance Industry in Nigeria. This publication also contains insightful articles, as well as recommendations for the sector. BusinessDay also plans to publish a larger report covering the entire spectrum of the health market in Nigeria and titled “Health Financing in Nigeria Report: Issues, Trends & Outlook.” Nigeria’s population is estimated at 186 million and is growing at 3 percent annually, with more than half of population under 30 years of age. The size and composition of Nigeria’s population makes it a vibrant health sector opportunity. Yet, government is incapable of fulfilling its obligations to the sector, thus placing a huge burden on the citizenry. Over the past decade, less than 7 percent of Nigeria’s annual budget has been allocated to healthcare. In 2018, the Federal Government has allocated N340.45 billion, which will account for representing 3.9 percent of the N8.6 trillion expenditure plan for the fiscal year.

In 2017, the amount was N304 billion representing 4.6 percent of the total budget. It is for this reason that the National Health Insurance Scheme was passed into law in May 1999 and the NHIS Act became fully operational in 2005 when the public sector aspect of the regulation was enacted. Despite the NHIS Act, only an estimated 5 to 6 million people out of the total Nigerian accounting for less than 5 percent of the populace are covered by health insurance. With about 60 Health Maintenance Organisations (HMOs) operating from approximately 600 branches nationwide, the health and managed care market can be described as emerging. Overall, the Industry employs over 2,000 employees and provides health insurance services via a network of over 1,200 healthcare providers across the country. The Industry size, in terms of revenues, is estimated to be over N300 billion. There is room for much growth in this Industry as a result of our population size and growing MSME and informal sector. All that is required is for the policy makers to provide the much needed reforms and strategic actions to the sector and the Industry will expand significantly. Overall, the healthcare industry in Nigeria is one of the most critically important and crucially fundamental sectors to any economy.

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

Objectives The Report is prepared intends to act as a policy communique to the policy makers on the issues and challenges impeding the growth and development of health and managed care, as well as healthcare financing in Nigeria. In addition, the report seeks to highlight to the readers and customers of the current situation, trends, outlook and recommendations to improve healthcare and the general wellbeing of Nigerians across all social classes, age groups and income levels. In addition to heralding the achievements of the Leading HMOs in Nigeria, the report also seeks to provide robust information on health insurance via articles and analysis, and is a forerunner to the comprehensive Health Financing Report that will be produced in the second quarter of this year.

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

Chapter 1

Overview of the Health Insurance Industry in Nigeria Omosomi Omomia

ver the past decade, less than 7 percent of Nigeriaâ&#x20AC;&#x2122;s annual budget has been allocated to healthcare. At no time in the last decade has government budget met the stipulated budgetary provision for the health sector of the Abuja Declaration of 2001, which stipulated that at least 15 percent of annual budgets of signatory countries should be devoted to healthcare on the African continent. Funds have been concentrated on recurring, rather than, capital expenditure, even though a wide deficit in physical infrastructure remains at government owned medical centers. In 2013, the Federal government budgeted 270 billion Naira for the health sector, representing 5.5 percent of the federal budget. In 2014, the federal government budgeted N216.40 billion representing 4.4 percent of the national budget, this

marked a 20.73 percent drop in the actual value of the health budget and in its share of the national budget. The health budget in 2015 was 237 billion Naira and about 5.5 percent of the national budget of N4.36 trillion. In 2016, total health budget of N282.1 billion accounted for 5 percent of the federal budget and in 2017, the amount was N304 billion representing 4.6 percent of the total budget. In 2018, the Federal Government has allocated N340.45 billion, which will account for representing 3.9 percent of the N8.6 trillion expenditure plan for the fiscal year. As a result of the significant financing gap, life expectancy rate in Nigeria of 53 years is below the global average of 72 years. Overall, in terms of healthcare budget capita, the country does not rank among the highest in Africa.

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

Budget Year

National Health Budget

Health Budget Per

(‘000 N)

Capita (N)

2013

270,000,000

1,571

2014

216,040,000

1,226

2015

237,000,000

1,308

2016

282,100,000

1,517

2017

304,000,000

1,634

2018

340,450,000

1,637

Nigeria’s population is estimated at 186 million and is growing at 3 percent annually, with more than half of population under 30 years of age, according to the National Population Commission (NPC). Population breakdown by the World Health Organisation (WHO) reflects that 44.3 percent of the population was under 15, those above 60 years were 4.5 percent while 15-59 year olds account for 51.2 percent of the population. The size and composition of Nigeria’s population makes it a vibrant health sector opportunity. Yet, government is incapable of fulfilling its obligations to the sector, thus placing a huge burden on the citizenry. It is for this reason that the National Health Insurance Scheme was passed into law in May 1999 and the NHIS Act became fully operational in 2005 when the public sector aspect of the regulation was enacted. The vision that undergirded the agency was to have a strong, dynamic and responsive

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

National Health Insurance Scheme 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 programmes/products of the Scheme. Presently only an estimated 5 to 6 million people out of the total Nigerian population of 186 million, representing about 3% of the populace are covered by health insurance. The reason for this is not farfetched. Part V, Section 16 of the Law states that “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…” As a result of this clause of optionality, there is an over-reliance on out-of- pocket payments in Nigeria. According to the World Bank, out-of-pocket expenditure accounted for 96 percent of private exp enditure on health in 2014 alone, in a country where 112 million people living on less

than a $1 (£0.63) a day. Subsequently, stakeholders in the Industry has posited that the NHIS Act 35 of 1999 regulating the practice of health insurance in the country needs to be amended to make participation in health insurance mandatory for the formal and informal sectors. The most crucial body of law is the National Health Act, which was signed into law in December 2014. It is the major single legislation which has given Nigeria a definite body of law that governs health care delivery in the country. Prior to this, there was no health legislation describing the national health system and defining the roles and responsibilities of the three tiers of government and other stakeholders in the health sector. The legislation is also crucial because it stipulates funding for the Healthcare of groups economically incapable of participation in the National Health Insurance Scheme. Subsequently, the Act provides that one per cent of the Consolidated Revenue Fund be charged to the Basic Health Care Provision Fund; Furthermore, 50% of the sum, is to be specifically allocated to the NHIS for the provision of Health Insurance coverage of the “vulnerable.” However, the government has not agreed on the most critical issue of the source of, and disbursement of the fund. Another challenge plaguing the industry is the role of the NHIS as both regulator and player. Consequently, with about 60 Health Main-

tenance Organisations (HMOs) operating from approximately 600 branches nationwide in an Industry catering to only 5 to 6 million enrollees out of a population of 186 million people, the Health Insurance Industry can be described as emerging. Despite this, the top 10 players account for a huge chunk of market share of estimated 55 percent of the total enrollees in the Industry, leaving the remaining 50 operators to cater to the balance of 45 percent. Overall, the Industry employs over 2,000 employees and provides health insurance services via a network of over 1,200 healthcare providers across the country. The Industry size, in terms of revenues, is estimated to be over N300 billion. Health, longevity of life and well-being being critical to human development and functionality, making health insurance mandatory for all employers in Nigeria is highly important for the nation’s human productivity, economic growth and national development. For instance, the Pension Reform Act of 2014 makes pension contributions for employers with 3 or more employees in the private sector mandatory. As a result of this, by the end of 2016, a total of N6.164 Trillion had accumulated in the Retirement Savings Accounts of the workers registered under the scheme. If that amount is taken into consideration for the Health Insurance Scheme, the figure represents 20 times the total health budget for Nigeria and 75 percent of the total federal budget for 2018. Imagine, the

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

quality of healthcare that would be achievable as a result, in terms of enhanced services, improved remuneration for medical practitioners and staff, significant investment in health infrastructure and equipment, provision of improved treatment and drugs, among others. Health, as they say, is wealth!

nations, healthcare can form an enormous part of a countryâ&#x20AC;&#x2122;s economy. With this publication, we seek to glean insights from 5 of the 10 Leading HMOs in Nigeria who have contributed, in no small measure, to advocacy, growth and development of healthcare in Nigeria and the quality of life of Nigerians.

Overall, the healthcare industry in Nigeria is one of the most critically important and crucially fundamental sectors to any economy. Globally, the industry is one of the worldâ&#x20AC;&#x2122;s largest and fastest-growing industries. Consuming over 10 percent of gross domestic product (GDP) of most developed

Source: Nigerian Civil Aviation Authority INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN (NCAA), NIGERIA

BusinessDay Research & Intelligence Unit

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

Chapter 2

The Health Insurance Market in Nigeria: The Way Forward

Introduction

he use of prepayment (health insurance) as the veritable means to guarantee access to affordable, cost effective and qualitative health care for all is a consensus pathway agreed and embraced by all the world over. The Health Insurance Industry in Nigeria is exactly twenty (20) years this year 2017. It was in 1997 when the pioneer set of Health Maintenance Organizations (HMOs) commenced the business of health insurance in Nigeria in the form Managed (Health) Care in the private corporate sector and retail business.

Dr. Tunde Ladele Chairman, Health and Managed Care Association of Nigeria (HMCAN)

The public sector came onboard eight years after in the year 2005 when the then Federal Government under the leadership of Chief Olusegun Obasanjo and

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

Prof. Eyitayo Lambo as Minister of Health launched the National Health Insurance Scheme for Federal civil servants. Thus, health insurance went full circle covering both private and public sectors. However, twenty years down the lane how as the industry fared? Can we say that we have achieved the different goals and milestones we needed achieve? No

doubt, some progress has been made and some lessons have been learnt and the system is more resilient now than when we started. However, there are still some steps that need to be taken to ensure that we get to where we want to be. The goal is universal health coverage. What are some the things that need to be done to ensure that the Health Insurance market covers the majority of Nigerians in the

foreseeable future?

Mandatory Participation Presently only about 5-6 million people out of the over 180 million Nigerian representing about 3% of the populace are covered by health insurance. To make the pursuit of universal health coverage a

reality and to bring about an appreciable positive shift in the health indices of the nation; participation in health insurance as a veritable means of health care financing to remove access barriers should be made mandatory. The NHIS Act 35 of 1999 regulating the practice of health insurance in the country needs to be amended to make partici-

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

pation in health insurance mandatory for the formal and informal sectors.

Participation by all Three Tiers of Government In the view of the fact health is on the concurrent legislative list; all the three tiers of government should ensure that

provide for the payment of the premiums of the vulnerable groups and indigent persons.

Robust Information Technology Platform There is an urgent need to put in place a robust IT platform to interconnect Regulators, health maintenance organizations, health care providers, clients, etc.

Stakeholders Respect for Service Level Agreements Contract fidelity â&#x20AC;&#x201C; respect for and compliance with business relationship agreements is an imperative. All stakeholders in the health insurance industry MUST abide with the terms of the bilateral, tripartite and multilateral contracts they have signed unto. The health insurance business is driven by reputational capital; therefore every stakeholder should ensure that they stay away from practices that will undermine the confidence of enrollees.

people within their political jurisdictions at the federal, state and local government levels are covered by health insurance. In enacting their health insurance laws they should make sure mandatory participation is a fundamental part of their legislation. So, that every Nigerian is covered by one form of insurance or the other. The three tiers of government should

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

For example, clients (public and private) should ensure that they pay their premiums in a timely fashion, so that HMOs can also pay their providers based on the claims turnaround times set forth in the contracts with providers. Health care providers should also avoid bad-mouthing, it is imperative that any gaps are discussed strictly with the relevant HMO and not to speak to enrollees. The tariff for services at least should remain stable within the contract period.

A situation where some providers increase the price of services in the middle of the contract and threaten not to threat enrollees if the new pricing is not taken should be corrected through the use of lock-in contracts, because HMOs are not able to vary the premium paid by clients in the middle of the contract year.

Discontinue Usurpation of Functions Each stakeholder in the health insurance value chain should face squarely their duties and obligations as stipulated by the law without crisscrossing into or usurping the functions of other stakeholders. Regulators should regulate, Operators should operate, Providers should provide and Users (enrollees) should use (utilize) services. The Regulator - NHIS should not be seen to be marketing or selling health insurance products; just as the CBN is not seen running commercial, merchant, microfinance banks or Bureau de change outlets, or the NCC seen marketing voice or data products as the Telecom providers, nor NAICOM seen selling life and general insurance policies. However, the Regulator may direct the industry players to pursue certain health insurance products it believes is in the best interest of all, i.e. after due consultation with all stakeholders.

Put an end to HMO Hopping Ensure that organizations do not port from one HMO to the other without first clearing outstanding indebtedness. The Regulator should ensure that no corporate organization or individual having been a health insurance policy holder with one health maintenance organization cannot port or change patronage to another HMO under any guise without first of all making good any indebtedness to the previous insurer. In practical terms, the Regulator should demand that any HMO wishing to sign on a client who is under another HMO or has been under health insurance cover before should request a Letter of Good Standing in terms of financial obligations from the previous HMO. The present situation were some clients disengage from one HMO and sign on with another HMO without fully liquidating their indebtedness to the previous HMO should be stopped through effective regulatory oversight. In conclusion, all hands should be on deck in the pursuit of universal health coverage for Nigeria as this is the only veritable means of securing the health asset of our populace and ensure a healthy and highly productive work force for nation building and achievement of individual prosperity.

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

Chapter 3

Improving Nigeria’s Health Insurance Coverage: Industry Perspectives and Recommendations. Introduction

eading political party manifestoes from countries across the World, one often comes across the terms “Free Healthcare” and “Subsidised Healthcare; leaving one with the impression that governments could miraculously lift the burden of payments for healthcare from the shoulders of citizens. This is a deliberately created misconception.

Dr. Leke Oshunniyi MD/CEO AIICO Multishield Ltd (HMO)

The citizens always pay for their own government provided healthcare, whether by way of taxation, direct contributions or levies. For many decades, Nigeria proved to be

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

the rare exception to the rule, spending oil revenue to fund the budget and neglecting tax revenue in the process. When in recent past, the precipitous drop in oil prices triggered a recession and a near collapse of the currency, the focus shifted to taxation, a more dependable source of revenue. Regrettably, the level of Tax compliance in Nigeria is very low. According to the Joint Tax Board, there are ten million people (precisely 10,006,304) registered for personal income tax purposes in all the states of the federation including the FCT. Out of this, about 4.6 million or 40% are registered with the Lagos State Internal Revenue Service (LIRS) indicating an average of 153,000 or 1.5% per state for others. Compared to the labour workforce estimated at 77 million at the end of 2015 according to the National Bureau of Statistics (NBS), the number of people in the tax net is only 13%. Total tax collection in Nigeria for the year 2017 by Federal and State agencies is still being collated, but is projected to be approximately N6 Trillion or about $20 Billion. This is an abysmal figure, when compared with the $60 Billion collected by our continental neighbour, South Africa, which has a smaller GDP and about one-third of our population. In other words, our tax collection efficiency is only about 10% that of South Africa. Suffice it to say that for the foreseeable future, the necessary activities of the three tiers of Nigerian government cannot be fully funded by taxation or petroleum revenues or the combination of both.

In 2014, private expenditure on health as a share of total health expenditure in Nigeria was almost 75%, clear evidence that government is incapable of fulfilling its obligations in the sector, thus placing a huge burden on the citizenry and debunking once and for all, the myth of Free Healthcare. The health funding scenario in Nigeria and other comparable economies led to the passing of Resolution 58.331 at the 58th World Health Assembly, urging member states:To ensure that health-financing systems include a method for prepayment of financial contributions for health care, with a view to sharing risk among the population and avoiding catastrophic health-care expenditure and impoverishment of individuals as a result of seeking care;

The NHIS Experience Though signed into law in May 1999, the NHIS Act became operational in 2005. As published in the October 2005 Edition of the Operational Guidelines of the NHIS, the stated Vision and Mission of the Organisation are recorded hereunder:

NHIS Vision A strong, dynamic and responsive National Health Insurance Scheme 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 programmes/ products of the Scheme.

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

NHIS Mission Our mission is 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 healthcare, through various prepayment programmes/products prior to their falling ill. This is in addition to providing regulatory oversight to Health Maintenance Organizations (HMOs) and participating Healthcare Providers. With an enrollee population of about 5 million people, representing about 3% of the country’s population, the NHIS can be considered to be well behind schedule regarding access to adequate and affordable healthcare and Universal Health Coverage The following are considered obligatory steps towards fulfilling the NHIS Vision and Mission, especially securing universal health coverage. 1) Re-enactment and Implementation of Appropriate & Effective Legislation.

The NHIS Act Passed in May 1999 on the eve of the departure of the Military, the Decree (now Act) Number 35 was flawed from inception. Without a proper, well drafted statute, the NHIS is bound to be hamstrung in the fulfillment of its mandate. A well drafted piece of regulatory legislation should have the following attributes:

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

The first attribute is that there is a shared agreement within the regulatory and policy communities and with key stakeholders on the generic attributes of good-quality regulation. Secondly, there is timely feedback on how regulatory regimes are performing in practice, relative to these attributes. Thirdly, there is the capacity to evaluate the feedback – to sort the wheat from the chaff – and a willingness to act when the situation requires it, based on empirical evidence and sound judgment.

A) tors

Scope of Compulsory Contribu-

¬Before considering the impact of Legislation on the Nigerian Health Insurance Industry, it is pertinent to examine another Nigerian law from a different industry entirely, but with a comparable socioeconomic impact. I refer to the Pension Reform Act of 2014. The Pension Reform Act, 2014 (“the Act”) established a Contributory Pension Scheme for payment of retirement benefits of employees of the Public Service of the Federation, the Federal Capital Territory and the Private Sector. Perhaps the most relevant clause to this discussion in the Pension Act was the Section 1(2)(b) of the Act which provides that the scheme applies to an organization with 3 (three) or more employees in the Private Sector.

By the end of 2016, a total of N6.164 Trillion had accumulated in the Retirement Savings Accounts of the workers registered under the scheme. This would never have been possible if the Pension Act was made optional. In contrast to the above, the NHIS Act which was enacted a full 5 years before the Pension Reform Act states in

Harmonisation of Definitions.

H) Errors of Syntax, Punctuation and Grammar. I) Removal of ambiguities in the name, objectives of the Scheme and functions of stakeholders.

Part V, Section 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 Councilâ&#x20AC;Ś. Other Amendments proposed in a re-enacted NHIS Act are: B) Name change to National Health Insurance Commission to avoid confusion of the Scheme with various Health Plans. C) Democratization of Act to remove all military terminology embedded therein. D) Composition of Council to better reflect stakeholder interests. E) Enhancement of the Regulatory Function of the NHIS. F) Revision of Penalties and Sanctions to reflect the more appropriate sanctions vis-a-vis the current value of our currency.

Implementation of the Provisions of the Health Act This crucial legislation, which incubated for many years and was eventually passed

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

in October 2014, holds the key to the provision of funds for the Healthcare of groups economically incapable of participation in the Scheme. The Act provides that one per cent of the Consolidated Revenue Fund be charged to the Basic Health Care Provision Fund; Furthermore, 50% of the sum, is to be specifically allocated to the NHIS for the provision of Health Insurance coverage of

Deployment of a Robust and Competent IT Infrastructure The NHIS has so far been unable to implement an ICT Infrastructure, which would ease the operation and effectiveness of the Scheme, and should borrow from the example of the USA where the Health Information Technology for Economic and Clinical Health (HITECH) Act was signed into law on February 17, 2009. With the prime objectives: To create a common platform for health information exchange …..through accessibility to accurate information on health care costs, quality, and outcomes. Develop interoperability specifications that identify harmonized standards and provide detailed technical specifications.

Large Scale NHIS Publicity/Awareness Campaign Despite the expenditure of considerable public funds on NHIS publicity, the impact has been less than satisfactory, and most Nigerians are unaware of the existence of this laudable Scheme.

the “vulnerable.” However, but government has not agreed on how to realise and disburse the fund.

A sustained large scale publicity campaign similar to that embarked on for the unforgettable War Against Indiscipline (WAI) of the 1980s should be articulated and implemented to popularise the Scheme, and increase coverage.

Collaboration with Local and International Governmental and Non-Governmental Agencies

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

A formal programme of collaboration with other entities engaged in healthcare delivery, and health advocacy, at all levels of government, foreign governments, donor agencies, health funds, philanthropic bodies or any other preventive health exercise should be embarked upon to reduce the national health burden and pressure on the Scheme.

Training of all Categories of participants Regular training programmes for all categories of stake-holders in the Scheme, to optimize participation and increase effectiveness in role performance under the NHIS, should be instituted.

Capacity Building for Operators of the Scheme Under the provisions of the Scheme, Health Management Organisations and healthcare providers are operators.

HMOs With the anticipated huge increase in the enrolled population expected with the legislative amendments, it would be necessary to request HMOs to increase their capacity by further mergers and acquisitions and increases of paid-up share capital to multiples of the current N400 million.

Healthcare Providers Although providing majority of the

Healthcare delivery under the NHIS, Private Healthcare providers under the Scheme are poorly equipped, with insufficient manpower competencies, inefficient and unsafe processes, leading to a concomitant worsening of treatment outcomes. NHIS should collaborate with an internationally renowned Hospital Rating Agency, such as Joint Commission International (JCI), to accredit healthcare providers under the Scheme. Support by the NHIS could be given to obtain necessary funding from financial institutions, to meet the aforementioned needs

Encouraging Amity, Goodwill and Cooperation Amongst Healthcare Professionals The relationship between the different professionals that make up the â&#x20AC;&#x153;Nigerian Health Teamâ&#x20AC;? Pharmacists, Nurses, Doctors, Medical Laboratory Scientists, Radiographers etc, can at best be described as frosty. Years of ill-defined role allocation by poorly drafted legislation particularly in the military era has left a legacy of hostility between the groups which may well jeopardise the smooth running and eventual success of the Scheme. No effort should be spared by NHIS in ensuring an atmosphere of peace and harmony between these professionals.

The NHIS as Societal Watchdog The NHIS must play a pro-active and interventionist role in combating myriad sociopolitical issues which impact on the health

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

of the nation to improve the risk profile of the covered population, notably: • Ignorance and illiteracy which beget unhealthy behaviour and pre-dispose to disease • Poor sanitation associated with gastro-intestinal maladies • Reckless driving and bad roads with horrifying road traffic accident statistics • Risky sexual behaviour and associated HIV/AIDS • Improper drainage and holo-endemic malaria •

Poverty and nutritional disorders

State Health Schemes

Why? The afore-mentioned NHIS Act 35 of 1999 had another major flaw; it failed to accommodate Nigeria’s federating units, the 36 States and the Federal Capital Territory on acceptable and equitable terms. Nevertheless, progress was made on that front. With the encouragement of international agencies such as the IFC, exactly 17 (Seventeen) years were to elapse before Lagos State passed the Health Scheme Act in May 2015, which made subscription mandatory for more than 20 million residents of the State. Operational modalities for the Scheme are being fashioned out, from which a quintupling in the existing Nigerian health insurance industry size is being anticipated in the near future. Furthermore, following the example of Lagos State, the other states have either passed or are on the verge of passing health insurance acts: - Abia, Kwara, Delta, Ekiti, Kano, Bauchi, Cross River, Ogun, Enugu, Anambra and Ebonyi.

The good news has deliberately been left to the last. More than 80 million Nigerians may be added to the health insurance pool in the very near future.

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

Chapter 4

Profiles of the leading Health Maintenance Organisations in Nigeria foremost brand offering comprehensive, affordable and accessible healthcare management; while its mission is to promote qualitative and affordable healthcare services using the best technology, processes and people. The HMO’s services comprise: • Medical Guidance: Provision of medical advice in line with the scope of the practice to restore or preserve the health of their clients.

AIICO Multishield AIICO Multishield is one of the foremost Health Maintenance Organisations in Nigeria. Licensed by the National Health Insurance Scheme (NHIS), the Company has been pioneering healthcare delivery since 1997. AIICO Multishield’s vision is to be the

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

• Impressive list of Healthcare centres: Engaging and deploying the best teams to promote quality assurance on all fronts and ensuring clients experience good service at all times. • In-depth comprehensive healthcare coverage: Guaranteeing a pool of resources and medical expertise to provide

quality healthcare services • High standard of healthcare delivery: Delivering value through quality health services managed by highly motivated and well rewarded healthcare professionals. The Company’s management team is led by Dr. Leke Oshunniyi, a seasoned Private Medical Practitioner and Health Administrator with over 35 years of experience.

AIICO Insurance Plc owns 92% of Multishield Limited. Multishield’s provider network is closely maintained to ensure members receive the best quality of care at all times. Members have access to customer service lines that are available on a 24/7 basis. Information is easily verified and assistance provided as required. The Company continuously innovates and leads in providing our members with access to programs that are designed to promote healthy living.

Extensive range of health plans Avon has applied its expertise to design a range of healthcare services that address the medical needs and preferences of the individual, family and employees.

AVON HMO Avon Healthcare Limited has been Nigeria’s most trusted HMO since 2013. The Company was duly registered by the regulatory authority (NHIS) to operate as a national HMO in October 2012 but commenced operations in 2013. The HMO is a subsidiary of the Heirs Holdings Group, an investment company committed to economic transformation of Africa. The Company’s purpose is to empower people across Nigeria to live healthier, fuller lives by providing access to quality healthcare services.

Focus on preventive care and wellness Many of the Company’s health plans cover preventive services which include routine check-ups, health screenings and immunizations.

Robust Provider Network Avon’s Provider Network is spread across the 36 states and major LGAs in the country.

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

Dedicated to quality assurance Avonâ&#x20AC;&#x2122;s emphasis on quality assurance and case management maintains the HMOâ&#x20AC;&#x2122;s standards of excellence and drives the ongoing improvement of the healthcare services delivered by their Provider Hospitals.

Responsive customer care

portance of being responsive to the service needs of our members. This is why we have a 24-hour Call Centre and a streamlined complaint resolution process Adesimbo Ukiri is the MD/CEO of Avon Healthcare Limited. Dr Awele Vivien Elumelu is Chairperson of Avon Healthcare Limited. She is also the Chief Executive Officer of Avon Medical Services Limited and oversees the healthcare investments of Heirs Holdings..

The Company recognises the critical im-

SURANCE CORPORATION, NIGER INSURANCE PLC and OMIS INVESTMENT LTD.

Healthcare International Healthcare International Limited is a private company incorporated in 1997 to provide quality and affordable health insurance to different strata of the Nigerian population. The company is owned by some of the leading insurance companies in Nigeria namely: AIICO INSURANCE PLC, COSMIC INSURANCE BROKERS, CUSTODIAN & ALLIED INSURANCE PLC, FEMI JOHNSON & CO., LASACO ASSURANCE PLC, NICON IN-

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

Healthcare International was conceived out of patriotic concern for the millions of Nigerians who lacked access to affordable health services coupled with the inherent challenges facing both hospitals and companies providing medical services to employees under the platform of retainership arrangement. The objective was to create a system that would address the pathetic circumstance and thus improve the health status of Nigerians in the process. In 1999, the company commenced full operation and in the same year the NHIS Act was signed into law. When NHIS rolled out its Formal Sector progamme for Federal Government employees, Healthcare International was among the first batch of 8 HMOs accredited to kick off the scheme and has since then grown in leaps and bounds.

The Company now provides services to about 24 government ministries and parastatals with over 400 private companies already enrolled under the different Private Health Insurance Plans. The over 500, 000 enrollees on different plans are being serviced by over 3,000 accredited Healthcare Providers including Clinics, Hospitals,

HYGEIA Hygeia has over 30 yearsâ&#x20AC;&#x2122; extensive experience implementing healthcare solutions to corporate and non- corporate clients that cut across all sectors of the economy with strategic investment from notable global institutional investors including Swiss Reinsurance Company Ltd, generally known as Swiss Re; International Finance corporation (IFC), the private sector arm of the World Bank Group; Investors For Health in Africa (IFHA), an Africa-focused Healthcare fund backed by FMO, Goldman Sachs and Social Investor Foundation for Africa; CIEL healthcare: A French healthcare company based in Mauritius, providing hospitals in partnership with Fortis Healthcare of India; and The Elebute Family: Professor and Professor Mrs. Elebute who are the founders of Hygeia HMO still remain shareholders.

Teaching Hospitals, Diagnostic Centres, Physiotherapy clinics, Dental and Optical Centres. The Chairman of the Board of Directors is Senator (Deacon) O.O. Omilani and the Managing Director/CEO is Tosin Awosika.

from the provision of managed care for private individuals through the JCI accredited Lagoon Hospitals which is a part of the Hygeia stable; to the provision of health insurance services to corporate clients for their staff. The HMO is currently driving the adoption of health insurance at most basic level which is directly by individuals. This serves to drive the goal of universal health coverage. Hygeia has also been active in driving the quality of care delivery and access and has contributed towards setting the standard for provider accreditation in the country. The Company serves over 632 corporate clients across 9 branches with over 1,032 healthcare providers at their disposal. Hygeiaâ&#x20AC;&#x2122;s management team is led by Mr. Obinnia Abajue, the Chief Executive Officer, while the Chairman of the Board of Directors is Mr. Max Coppoolse.

Hygeia has been at the forefront of health care provision in Nigeria. We have evolved

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

eral Capital Territory.

Total Health Trust (THT) Total Health Trust Limited (THT) was founded in the year 1997 by a group of 3 general medical practitioners and a corporate angel investor. THT commenced full operations in June 1998, thus we pioneered health insurance in Nigeria and we predated the introduction of the NHIS. With over 320,000 members or subscribers, representing about 8% of the estimated population of the organised private sector with medical insurance coverage to date, it is one of the largest HMOs in the Country. THT was reaccredited in 2009 and has duly passed its most recent reaccreditation as a National HMO in July 2014. Total Health Trust, in keeping with its focus on customer service and promotion of member health, offers a range of innovative costeffective health plans and tariff structures. Under this arrangement, THT members receive health coverage from in-country providers and in some circumstances, also benefit from international coverage.

In 2013 the company was acquired by Liberty Group of South Africa in order to further enhance the insurance resources, processing systems and the international exposure of international best practice. Total Health Trust continues to build upon its reputation for excellent service delivery by treating its valued clients with the utmost respect, compassion, expertise and pride. The THT 24-hour full service Call Centre â&#x20AC;&#x201C; which is manned by trained medical staff â&#x20AC;&#x201C; handles over 500 calls on a daily basis with up to 5,000 calls per week received from enrollees across the country. With the THT head office based in Lagos and 10 zonal offices all over Nigeria in Abuja, Ilorin, Enugu, Yola, Ibadan, Port Harcourt, Abeokuta, Kaduna, Calabar and Benin, the company maintains points of presence for contact by its enrollees to facilitate access and coordination of care. With staff strength of over 200 persons working in a multicultural, diverse environment and a continuous investment in human capital development, THT remains an employer of choice within the industry. It is no wonder that THT is a household name in Nigeria with respect to service delivery and has won the HMO of the Year Award for 2016 and 2017 consecutively.

The healthcare provider network consists of several (300 Private & 1,550 NHIS) accredited clinics and hospitals where quality of care is guaranteed through a programme of continuous monitoring. The provider network has points of presence in all 36 states of the federation and the Fed-

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

Chapter 5

Avon HMO: Five Years of Setting the Bar in Nigeriaâ&#x20AC;&#x2122;s HMO Industry and Next Steps

hen Avon Healthcare Limited (Avon HMO) entered the Health Insurance market back in 2012, the company made it clear that its mission was to empower Nigerians to live healthier and fuller lives. It was a tough mandate indeed. With a population of more than 170 million people, majority of whom live below the poverty line, access to quality and affordable healthcare was a huge challenge. Even though there were over sixty (60) HMOs in operation, growth was stifled due to low public awareness levels, frequent hospital/provider disputes, a lax regulatory framework, poor product differentiation, lack of flexibility by the operators (HMOs), amongst other factors.

Avon HMO stepped in to the industry with a focus to address these factors and more. As a first step, the organisation championed healthcare inclusion for the vast majority of Nigerians who did not fit into the traditional HMO target market of corporate sector players and multinationals. Accordingly, while most of the competition was fixated on the corporate sector, Avon pioneered a shift into retail by developing a range of health plans to meet the healthcare needs of the everyday Nigerian, whatever their stage in life. This includes entrepreneurs, SMEs, students, young entrepreneurs, couples intending to get married and families.

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

Avon HMO is also driving innovation in the Nigerian health management space with its online platform, ‘Avon HMO Online’, which enables Nigerians buy and manage their health plan subscriptions from any internet-enabled device without the burden of having to visit a physical office. So, from the comfort of their homes and offices, irrespective of the time or day, subscribers can choose and pay for their preferred health plans, browse what medical services are covered in the plans and even check for hospitals nearest to them all with the click of a button. This landmark achievement essentially eliminated most of the barriers to accessing quality healthcare in the country, in addition to birthing the digital era in Nigerian HMO space. At the heart of Avon HMO’s mission is the role to educate the public on the benefits of subscribing to a health plan. By bringing people together and pooling their finances, members of the group can be cared for and everyone will have access to quality health care services whenever they need it. For many Nigerians earning an income and can afford to put money aside for their health, Avon HMO actively encourages them to subscribe to a health plan. This is not without its challenges however. In order to achieve widespread coverage on the path to making Universal Health Coverage (UHC) in Nigeria, there is a need for a regulator with the political will to put the right framework in place, monitor operators (HMOs) and ensure that our healthcare ecosystem actually works. As a regulator, it should have the capacity to enforce the regulations -- With over 60 licensed HMO operators, there

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

is much to monitor and implement. For example, the HMO industry could do with a consolidation exercise that will result in Nigerians being served by more credible operators, with the financial strength and capacity to take the industry forward. The above factors, coupled with a general distrust of insurance contribute in no small measure to the degree of apathy exhibited by Nigerians who are aware of what HMOs bring to the table. Past antecedents of some HMOs using substandard providers or owing hospitals, thus resulting in enrolees being denied care haven’t helped either. This is why Avon HMO emphasises managed care rather than health insurance, while also putting in place internal processes to enable it stand out from the pack. One of these is the company’s quality assurance process; Avon HMO boasts a rigorous quality assurance model which comes into play right from the selection of partner hospitals to the supervision of the care enrolees receive from the hospitals. However, Avon’s relationship with partner hospitals goes deeper than being merely supervisory. Since inception, the company has maintained a standard operational practice of ensuring that providers are paid what is due them at the appropriate time. It also maintains regular engagement with partner hospitals in a bid to foster mutual understanding with them. An off-shoot of this is the Avon HMO Providers’ Forum, a first-in-class stakeholders’ engagement forum where Avon recognizes and rewards hospitals for their outstanding efforts in providing healthcare to Avon HMO enrolees.

The company also has a disease management framework through which individuals with specific diseases or conditions are identified in order to make planned proactive care available, as part of a holistic preventive approach towards healthcare. Avon does this by tracking the performance of every individual’s care with hospitals, receiving feedback on their performance and then interacting with the individuals involved to ensure patientcentred care is achieved. In addition, Avon HMO runs a drug formulary which is a list of prescription drugs, both generic and brand name, used by practitioners to identify drugs that offer the greatest overall value. The formulary is monitored by in-house professionals (Doctors, nurses and pharmacists) as a costeffective and efficient way to monitor what medication is being provided to each enrolee when they receive care in partner hospitals. Avon HMO prides itself as a responsible corporate citizen and a supporter of government’s efforts to sanitize the industry. The company enjoys a cordial relationship with the industry regulatory body, the Nigerian Health Insurance Scheme (NHIS) and it is a testimony to Avon’s exemplary compliance record that in five years of existence, it has never received a complaint of infraction neither has it been penalised by the regulator. Nevertheless, Avon HMO continues to lead the advocacy for a stronger regulatory environment as it believes that this is necessary for the sustainability of the industry. From the start of operations, Avon HMO has advanced the case for digitalization and big data to drive efficiency in an industry severely bogged down by manual

processes. The organization describes itself as occupying a unique position in the intersection between health and technology. All data sits in the cloud, whether it be utilization data or experience data of enrolled members at the hospital. This ensures that operations are not unduly hampered by loss or damage from physical storage. Big data also provides the brand with predictive technology which it foresees will be huge in the health sector in the coming years. For the CEO, Adesimbo Ukiri, the coming years will be exciting for the health sector as big data will help HMOs predict who would fall ill to certain medical conditions, when they will and in what numbers. “I look forward to us, as a country, being able to have data on healthcare spend and utilization that will enable us to look into the future and also help us plan adequately for the kind of medical infrastructure and access to medical finance that the country needs. As a company, Avon has always spoken about data from inception. We started by putting our operating software in the cloud so from the get go, we were passionate that even if nobody else was keeping medical data at the granular level, we will. So, from the years that we have been in operation, we have data. But wouldn’t it be wonderful if all the HMOs and hospitals had the same level of granular data? I think that as a country, we need to begin to lay more emphasis on this because the gains for us will be really tremendous,” Ukiri says. Beyond operational, legal and regulatory issues however, Avon believes that all stakeholders must work together to

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

achieve Universal Health Coverage in the country. It argues that while government at all levels struggle with financing healthcare services, HMOs are well positioned to pool resources together to complement governmentâ&#x20AC;&#x2122;s efforts in such areas as quality assurance, marketing, awareness creation, and public education, which government has limited capacity to invest in.

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

Five years since opening its doors and Avon HMO is doggedly proving naysayers wrong. The company continues to set the bar with its commitment to delivering innovative services as well as itâ&#x20AC;&#x2122;s adherence to global best practices. Avon HMO, a subsidiary of Heirs Holdings, is now widely acknowledged as a game changer in the Nigerian Health Insurance sector.

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

Chapter 6

Healthcare International RePositions For Better Service Delivery

ealthcare International is a foremost national Health Maintenance Organization (HMO) accredited by the National Health Insurance Scheme (NHIS) to deliver quality managed care services to individuals, families, groups and organizations. We were established in 1999 and owned by some leading insurance and brokerage companies in Nigeria. These include AIICO Insurance Plc, Custodian and Allied Insurance Plc, Femi Johnson and Co., LASACO Assurance Plc, Niger Insurance Plc, NICON Insurance Corporation and OMIS Investment Limited. We currently manage an enrollee base of over 400,000 lives through our partnership with over 1,000 hospitals and a strong operational presence in each of the six (6) geopolitical zones of Nigeria. As part of efforts to improve service delivery to our numerous customers and other stakeholders, we are pleased to inform our esteemed customers, partners and members of the general public that we have just concluded the process of restructuring our business operations. The scope of the strategic exercise included, amongst others, a comprehensive review of our Internal Business Process to make it more efficient, customer-centric and to create a happy and memorable service experience for our customers.

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

Consequently, and with a view to further strengthening our service delivery capabilities, we have relocated our corporate headquarters to 296, Herbert Macaulay Way, Yaba, Lagos. It is our belief that this will make us more easily accessible to our clients, partners and members of the general public. We are also in the process of rebranding our Corporate Identity in order to keep abreast of the trends and dynamics of our target market and also to more deeply connect and identify with the aspirations of our customers. With well-motivated staff; and current cutting-edge technology, we are now better positioned and committed to providing better solutions and delivering more value to our customers. Call us today on 01-4489821, 07030009099 or visit www.healthcare-ng.com

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

Chapter 7

â&#x20AC;&#x2DC;I envision a more consolidated industry with fewer but tried, trusted and stronger players... To what extent does Total Health Trust involve itself in corporate social responsibility activities and charitable initiatives in the country? THT has been actively involved in a number of CSR projects. Last year alone, we ran a fund raising event for a cancer foundation which is dedicated to providing support for people living with cancer. In addition, we also made donations to a school for children with special needs. This year, we have also supported the special needs school in line with our yearly corporate social responsibility. We have additionally earmarked other CSR causes to support all

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

Dr. Ladi Awosika Chairman, Total Health Trust Limited

within enhancing the welfare of community around us before the year runs out. From over 70 health maintenance organisations in 2015, there are currently 60 HMOs spread across the country in 2017. How do you see this number evolving in the future? Based on increasingly stringent operating requirements from the regulatory perspective, I envision a more consolidated industry with fewer but tried, trusted and stronger players with the capabilities required to drive the Universal Health Coverage agenda. Already, we see that some States which are rolling out mandatory health insurance are limiting the number of players for effectiveness. I therefore see an industry where consolidation through mergers and or acquisitions will occur as well as increasing dominance/competition from foreign/ newer entrants with formidable health insurance administration expertise and technology from well-developed international markets.

As a player in the Health Insurance Industry, what are the peculiar issues you encounter in successfully operating and providing quality healthcare to your enrollees, clients and customers? The major challenge we face, just like other HMOs in Nigeria would be the low penetration of health insurance. This has been linked to the understanding of the popu-

lace about insurance in general of which health insurance is a part of. Culturally as well, the average Nigerian would not invest in health insurance as they believe this is an invitation to ill health. Another challenge we face is in the issue of public health insurance. Nigeria is a federal state with different tiers of government maintaining reserved powers. While the federal government has moved to insure federal public servants, many States are yet to do same at the State level. It should be mandatory at all levels of government so that everybody can be captured under one umbrella. The rising costs of healthcare is also a challenge that cannot be ignored.

What is your assessment of the Health Insurance segment of the Health Industry today? The health insurance industry is supposed to be pivotal in addressing the demand side of the poor health financing status of the country. The NHIS law enacted in 1999 was to provide regulation and direction towards attainment of Universal Health Coverage within 10 years after commencement in 2004. However poor implementation and professional leadership coupled with lack of political will and direction in our supposed federal system have stifled the attainment of the mission and vision of the industry. The important element of mandate for every Nigerian to belong to a prepaid health scheme (private or public) has unfortunately not garnered the necessary political will.

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

The health insurance industry has the capacity and human resources to scale up to expand the scope and breadth of coverage when that mandate becomes law. We are all aware that even with the mandate, we shall still be decades away from 100% universal coverage, however where there is political will, sustainable solutions will be forthcoming. Health insurance practitioners have over the years been developing the knowledge base and operational capacity to scale up.

The NHIS has covered less than 5% of Nigeriaâ&#x20AC;&#x2122;s population. What, in your opinion, are possible strategies and initiatives that can result in the expansion and growth of the Scheme in Nigeria? The health Insurance Law should make it mandatory that all Nigerians contribute into pre-paid health schemes. At this time and by the nature of our country, we need several pools that shall be under the oversight of a capably led Regulator. Thus private and public, commercial and not-forprofit pools are all required to address the

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

needs of all segments of the population. National, State and Local governments must be ready and willing to contribute into pools on behalf of the poor and lessprivileged in society.

a. Enactment of new Bill to mandate health insurance membership b. Bill that transforms the NHIS into a full regulator with appointment of capable leadership with cognate financial and insurance management experience c. Bill that separates the Contributed Funds from the regulator d. Ensure that Boards are properly constituted and empowered with knowledgeable patriots. e. Proactive regulation such as obtains in PENCOM, NAICOM and NCC. f.

Properly regulated broker channel.

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

Chapter 8

‘Without a new law, there would be a bitter struggle by operators to capture less than 4% of the population enrolled.’ Please enlighten us on the events and circumstances that led to the establishment of AIICO Multishield? Comparable with many similar undertakings, the circumstances were multi-factorial. The practice I worked for was very innovative, and sometime in the mid-eighties, we struck a health insurance agreement with the Nigerian subsidiary of an American

Dr. Leke Oshunniyi – Managing Director, AIICO Multishield

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

company to provide medical cover for a whole year, for about 200 employees for the sum of N50,000. To put that amount into perspective, that could have bought 4 luxury saloon cars at the time. In line with the longstanding convention in the USA, the company wanted to budget for health, rather than leave staff healthcare as an open-ended expense item as was and still is the practice with many corporations here. To cut a long story short, we were able to run the programme successfully in the first year and subsequently. The net effect was that all the top practitioners in the practice became lifelong advocates of health insurance. Since we were all active in the Association of General and Private Medical Practitioners of Nigeria (AGPMPN), we were able to collaborate with other frontline private medical practitioners and the Nigerian Medical Association to convince the then Minister of Health, the late great Professor Olikoye Ransome-Kuti to initiate protocols for national adoption. The process was exceedingly slow, but by the mid-nineties, it was obvious to industry watchers that the enactment of a decree to regulate the operations of the fledgling health insurance industry was imminent. Added to that, was the accelerating global trend of incorporating health pooling mechanisms (or health insurance) in health funding strategies. AIICO Multishield was one of several HMOs incorporated during this period in anticipation of the official flag-off of the industry in Nigeria. It is pertinent to note that we started operations in 1997, two years before the enactment of the Decree (now Act) 35 of 1999. We are happy to be cel-

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

ebrating our 20th Anniversary this year.

As one of the foremost Health Insurance Providers in Nigeria, do enlighten us on AIICO Multishieldâ&#x20AC;&#x2122;s achievements and contributions to healthcare and the Health & Managed Care market in Nigeria. AIICO Insurance Plc provided the inimitable leadership, financial support and corporate advisory services without which it would have been impossible to scale a rigorous audit process conducted by Agusto and Co. in 2004/2005. Thereafter we were licensed as one of the 8 pioneer health maintenance companies in Nigeria. Since then, we have been in the forefront of innovations in the industry. The provision of Managed Care for Youth Corpers in their service year was one of our corporate initiatives which was adopted by the NYSC Directorate and operated for several years until funding for the project was stopped. AIICO Multishield was also the first HMO to digitalise enrollee access to healthcare and the management of the benefit packages. Being a subsidiary of the insurance giant, the AIICO Insurance Plc, we have been able to roll-out bundled or combined life and healthcare products for the benefit of thousands of our customers. If you look at page 103 of the Economic Recovery and Growth Plan document of the Federal Republic of Nigeria, you will find mentioned under Programme 32 (Roll-out of Universal Health Coverage), the item â&#x20AC;&#x153;Scale up Mobile Health Insur-

ance to provide coverage for the poor”. I am very proud to say AIICO Multishield Ltd was an integral part of the team that conceptualised and operated Mobile Health Insurance, a global first.

As an industry expert, please provide an overview on the Health & Managed Care market? The health value chain, is quite extensive, including: provision of healthcare, training of health workers, financing of care, manufacturing of pharmaceuticals/consumables and their distribution and retailing. If you take sub-sectors of the health value chain, financing of care probably accounts for about 10% of the entire value chain, whilst provision accounts for 50% and training 10%. The remainder is shared by the other sub-sectors. The premiums for the private managed care component in Nigeria averages about N30,000 to N40,000 per annum. At the current exchange rate, this equates to about $100 per annum. Yet most of our therapeutics and consumables are imported. In comparison, the average annual premium for health insurance in the USA hit $10,345 in 2016, a hundred-fold difference. Furthermore, less than 4% of approximately 180 million Nigerians are enrolled with a health plan. On a global scale, it has been estimated that Sub-Saharan Africa (SSA) bears up to a disproportionate 24% of the global disease burden, but struggles with 3% of the world’s health workers and less than 1% of the world’s finance. Divide these figures by a factor of 4, which is the approximate

population ratio of Nigeria to the whole SSA, it gives you an idea of the long road we have to travel.

What is your evaluation of the Healthcare Industry in Nigeria today vis-à-vis the country’s counterparts in the West African region and in Africa? I am not conversant with the policies of our Francophone neighbours, but the efforts of our Anglophone neighbour, Ghana, have been well publicised. Ghana appears to be much more determined to achieve Universal Health Coverage than we are, even though the regulatory statute was passed into law in 2003, a full four years after the Nigerian equivalent; indeed they came to Nigeria to learn about the industry. What Ghana did, included the establishment of a schedule of contributions from workers and the setting aside of 2.5% of the price of certain goods as part of Value Added Tax (this accounts for 70% of the funding). Little wonder then, that Ghana has a health insurance enrolment compliance of over 40% of the population. Incredibly, Ghana’s performance in this regard is beggared by the achievement of Rwanda with which has achieved a 96% health insurance coverage in a few short years.

What impact has the recent economic recovery had on the Health Insurance and Healthcare Industry in Nigeria? The economy is on the path to recovery; it has not yet recovered, and may not reach 2014 levels for a few years. Economists will

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

tell you that medical businesses tend to be agnostic of business cycles and models of Government. However, what we have seen locally is that the economic downturn has meant people are less likely to pay premiums and more likely to resist increases thereof. Also the cost of care delivery by providers has skyrocketed. HMOs have been caught in the middle of these two effects of the recession.

What are the current trends prevalent in the industry? There is stagnation in the industry. The efforts of the HMO umbrella body, the Health and Managed Care Association of Nigeria (HMCAN), under the able leadership of our Chairman, Dr. Tunde Ladele, have been geared towards the repeal and re-enactment of Act 35 of 1999. Perhaps due to a lack of experience or insincerity on the part of the authors of this piece of legislation, it was an unsound statute from the day it was passed. HMCAN has worked tirelessly for a modification of the law since the day it was enacted. It is reflective of our aggregate attitude to health in Nigeria that there has been such little progress in over 18 years. In the meantime the Pension Act was passed in 2004, amended in 2014, and there are indications that a further modification is in the offing. The past few years have been a period of learning, and we hope that lessons learnt can be incorporated into a new law which will usher in an era of exponential growth in the industry.

Where do you see your industry in the near to medium terms in INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

terms of competition, growth and development? Without the appropriate legal framework, issues of growth and development will remain moot points. As for competition, without a new law, there would be a bitter struggle by operators to capture the patronage of the less than 4% of the population enrolled. A price war could well ensue, and the outcome, even for the victor would be pyrrhic.

How has policy-making and execution by regulators influenced operations in the Industry? Everything leads back to the regulatory environment. Which brings us to the question - What makes Good Regulation? In his seminal paper on the subject written in 2007, Stavros B. Thomadakis summarised the attributes of good regulation as follows: The first attribute is that there is a shared agreement within the regulatory and policy communities and with key stakeholders on the generic attributes of good-quality regulation. Secondly, there is timely feedback on how regulatory regimes are performing in practice, relative to these attributes. Thirdly, there is the capacity to evaluate the feedback â&#x20AC;&#x201C; to sort the wheat from the chaff â&#x20AC;&#x201C; and a willingness to act when the situation requires it, based on empirical evidence and sound judgment. Our regulatory environment in the industry is in need of a complete overhaul. Only then can we begin to discuss policy-making and execution by regulators.

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

Chapter 9

â&#x20AC;&#x2DC;Most Nigerians are not aware and do not understand or appreciate the need for health insurance.â&#x20AC;&#x2122; Interview

You possess 20 years of sound banking experience. What are the events or circumstances that led you to become the CEO of Hygeia HMO? Well, banking is probably the most sophisticated services industry in Nigeria today and having worked with some of the finest and leading financial institutions in Nigeria and Africa, I believed that it was time for me to apply that learning and experience to an area with a bigger impact on the Nigerian society.

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

Mr. Obinnia Abajue Managing Director, Hygeia HMO

The fundamentals of any society are its education and its health systems. Investment in these areas is what guarantees the availability of human resources/skill and the competitiveness of the society and its labour force over time. The biggest attraction of developed countries to our people which is what supports emigration is the opportunity for a better education and/ or healthcare. It may also surprise you that the biggest deficits in labour are also in these areas so continuing improvement of these sectors provides for increased employment opportunities in these societies. In addition, when you consider the maturity of our country and the gradual reduction of maternal and infant mortality, the demand for better health care and access to it means that there is a significant opportunity for intermediation and inclusion in the health sector. So, it made sense, when the opportunity presented itself for me to move into the health insurance industry to contribute my quota to developing Nigeria actively.

We have also introduced novel â&#x20AC;&#x153;No Authorizationâ&#x20AC;? policy for primary care services to improve or eliminate wait times at Hospitals. Very soon, our clients will have the added benefit of telemedicine services where they can consult remotely to increase their speed and access to basic health services and to beat the traffic and distance issues. I would therefore say that our plans, products and services are appropriate, affordable, transparent and convenient to use.

Please enlighten us on your plans, products & services and what makes them unique?

As an industry expert, can you provide information on the Health Insurance Industry in Nigeria?

At the heart of mission at Hygeia HMO is the provision of affordable access to quality healthcare. We are committed to making healthcare available for all. In keeping with our mission, we have developed plans that cater to the needs of various Individual, SME and Corporate needs in the market.

Unfortunately, the health insurance industry is still very small and fragmented and data is not readily available. This is one of the issues that is paramount to be resolved by the industry association and regulator. From what we know today, there are about 60 HMOs operating in Nigeria. Most of them are regional operators with a few as national operators. Hygeia HMO is a National Operator with presence across the country. We have provider relationships in every state of the federation and of-

So whatever your category, Hygeia is able to take care of you.

To ensure that our enrollees/beneficiaries across the country are able to access healthcare more easily, we are also putting more power in the hand of our enrollees via our Hygeia Mobile App. This was introduced to improve transparency and service quality. Our App enables enrollees to: reduce wait times in the clinics, have 24/7 access to their medical benefits, locate nearby hospitals through geo-tagging functions as well as track utilization of medical benefits per time, e.t.c.

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

fice is each geo-political zone. The market penetration or health insurance coverage is very low, estimated at about 3% of the population. Herein lies the opportunity.

What is your evaluation of the Health Industry today, especially with respect to the regulatory and business environment? Although the general estimate of coverage is about 3%, only an estimated 1% of Nigerians have been covered by the National Health Insurance Scheme (NHIS) in the 12 years of its existence which suggests that the balance is covered via private schemes. However recent trends seem to show an increased uptake in the advocacy to achieving UHC in Nigeria. A memorandum approved by the National Council on Health currently empowers states to sign their own health insurance bills. In just over two years since that memorandum was signed, more than 5 states including Lagos have passed health insurance bills tailored to meet the needs of their communities. There is much work to do across the full health value chain to improve coverage and develop a long term sustainable health sector. Attention is needed to creating awareness of the availability and need for health insurance to enable funding for health sector development. In addition, investment is also required in capacity building given the incredible deficiency that Nigeria has of health sector personnel. Across all the various parts of the industry, we do not produce enough people and we lose a lot of the trained staff to foreign countries because of their better

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

career opportunities. So we need to invest in making our health sector more attractive for our home grown talent to remain and work therein. The introduction of state schemes is a great idea but it does not resolve the 2 core areas of investment above and states need also to support actively the development of health personnel and the increased awareness of health insurance so that individuals can be willing to pay at whatever level hey can afford to access some health care. While compulsion is desirable, it is more important that there is a better understanding of the process and the service.

As an industry insider and expert, what are the constraints in the Sector and what strategies has Hygeia put in place to mitigate those threats? Limited awareness is a major issue as most Nigerians are not aware and do not understand or appreciate the need for health insurance. This is why we see so many cases of people begging for assistance to take care of health conditions/issues that have befallen them or their loved ones. Most of these were avoidable if they had purchased health plans when they were healthy. They would have had access to periodic health checks and would have been in a position to detect and manage the conditions early before they degenerated. A key benefit of health insurance is the reduction of the financial risk of ill-health which many have not taken advantage of. Additional issues that impact the industry include that absence of provider regulation and quality standards for hospital care

and management. There are also issues of fraud and the limited availability of data which impacts product development and risk management. Hygeia is working with various partners to address most of these issues starting with product development and awareness through various media and channels. We are deploying technology across the value chain to improve access to healthcare as well as improve the transparency and service process for healthcare access. Services like our mobile app, online claims payment for providers and USSD verification tools help to improve access to healthcare while protecting against identity fraud at hospitals. Hygeia is a thoughtleader in the health industry and responsible for critical engagement fora for key industry participants What are the current trends prevalent in the industry? Where do you see your industry in the next 5 years in terms of growth and evolution? There is currently a lot of focus on new investments in hospitals and some in health industry technology. However, over the next few years, I see the top 2 issues being: (1) Technology because of the environmental constraints. Awareness and capacity deficiency can be mitigated by technology adoption. Smartphone technology is getting cheaper still and more available and affordable while health apps and virtual reality technology are also coming mainstream. These developments will make it easier to reach more people for preventive and primary

care services. Self Service technology also means that more people can get help through non-traditional medical centres reducing the need to more specialised medical centres. (2) Health insurance coverage because the assurance of payment is critical for investment and the access to finance is based on guaranteed cash flows which are only available with health insurance. Furthermore increased risk awareness will encourage more people to see to transfer the financial burden of ill health which will drive product development and demand for insurance products in the health space. Based on the above, I expect significant growth in the health insurance industry over the next few years not only in terms of market penetration and coverage but also a significant increase in technological sophistication. Overall, what are your Organisationâ&#x20AC;&#x2122;s plans for the near future to maintain your leadership status as well as consolidate your position as number one in the Health Insurance sector in the Nigeria? Hygeiaâ&#x20AC;&#x2122;s mission is to provide affordable access to quality health care. This requires us to focus intensely on both the customer and the provider experience. Our plans are directed at ensuring that customers that buy health insurance across the country are assured of a minimum standard of service and quality of care irrespective of the premium paid. We also aim to support the providers and medical service practitioners to run profitable and sustainable operations. The combination of these should

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

result in good healthcare delivery for our clients and a profitable outcome for the providers. Finally, we believe that over the long term we will play an active role in policy formulation to improve the quality of the discourse and overall industry development.

Is there any other thing youâ&#x20AC;&#x2122;d like to add? We believe that access to healthcare is a right. But healthcare is not free or cheap. It is important that all individuals take responsibility for their healthcare and en-

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

sure that they have access to health care whether or not someone is paying for them. My advice to those that are able is that each person should take the responsibility for ensuring that those in their immediate environment are covered. An epidemic is as likely to impact the rich as it is the poor. Everyone is connected and every life matters. Health insurance is the most feasible way to ensure people have access to healthcare no matter how basic the cover is. Hygeia HMO as a leader in the market is working to help everyone get healthcare.

Chapter 10

How Avon HMO is Driving Healthcare Inclusion in Retail Sector - Avon CEO.

ith her wealth of knowledge in health insurance, one can be forgiven for thinking that Adesimbo Ukiri, the Chief Executive Officer and Managing Director of Avon Healthcare Limited, has been working in the industry all of her life. However, she has enjoyed a career that has spanned financial services, FMCGs and telecommunications before being thrust into the driver’s seat at Avon HMO. In her capacity as the CEO, she has, over the past five years, nurtured the company into one of Nigeria’s leading HMOs.

Adesimbo Ukiri CEO, AVON HMO

She spoke with OBOKOH ANTHONIA & MICHAEL ANI on a number of issues including why Avon is leading the charge to

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

penetrate the retail sector with affordable health insurance packages and the state of affairs in Nigeria’s health sector. Excerpts:

When Avon HMO announced its entry into the Health Insurance market, the brand’s Unique Selling Point was to crack the retail sector. Five years down the line, how has Avon fared in meeting this objective? First, let me clarify that our business model is hinged on the Health Management or Managed Healthcare model as opposed to the Health Insurance model. The difference is that the typical health insurance company underwrites people individually. For instance, they will assess the risk profile of an individual and charge a premium based on the risk assessment. However, another customer of exactly the same age but with a different health risk profile will be charged a radically different premium by the same company. That is how health insurance works. What Avon does is to manage people’s healthcare based on their subscription to specific health plans. So, unlike the health insurance model which underwrites people individually, our model is to get a pool of people together and make some assumptions about their health status like; how many people will be ill at any point in time within the pool, what kind of illness they will have, etc. That way, everybody pays exactly the same fee as long as they are subscribed to the same health plan. The bottom-line is that the managed healthcare system doesn’t discriminate. For us, no matter the health plan you

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

choose, you will only pay what others in that particular category are paying. Also, unlike the Health Insurance model, we have nurtured relationships with hospitals. A key part of our engagement with the hospitals is to ensure that they adhere to certain quality standards when they treat our enrolees. It’s important to make that clarification so that people understand who we are and what Avon HMO stands for. Now to your question about Avon’s efforts in cracking the retail sector; prior to our entry into the market, there were about 70 licensed Health Maintenance Organizations (HMOs), many of which had been in existence for about 10 years or more. However, none was able to surmount the challenge of penetrating the retail sector. When we started operations about five years ago, penetration was low. I think we had less than three per cent of the total population covered at the time even though we knew that the informal sector is way bigger than the formal sector in Nigeria. We saw that as a great opportunity and entered the market with health subscription offerings specifically tailored to meet the needs of people in the retail sector. This is not to say that we turned our backs on the corporate segment of the market. However, while our peers were busy looking for the corporates, we studied the retail sector and came up with bespoke health plans that answered their specific needs. Feedback so far has been good and though we have made some remarkable strides we are not resting on our oars. Not too long ago, we announced the introduction of new plans to meet the needs of unserved Nigerians who do not

fit into the traditional HMO target market. Again, we have gotten excellent feedback from these efforts.

higher benefits than the life starter and is mostly targeted at people approaching middle age. Premium Life is also targeted at people who fall intothe middle-age and

We realize that we are on a journey. We havenâ&#x20AC;&#x2122;t gotten to our destination yet but we are encouraged with the impact we have made thus far. For us, it is a marathon and not a sprint.

above category but it offers a robust cover of advanced diagnostic tests,

You just mentioned that Avon HMO recently introduced a new bouquet of Health subscription plans specifically designed for unserved Nigerians. What makes them different from the array of plans already existing in the market? Avon HMO came up with six new plans specifically created for the retail sector in order to further bridge the gap in ensuring that Nigerians get quality access to affordable healthcare. We have the Life Starter plan, which, at a very affordable cost, takes care of all general outpatient diseases, minor and intermediate surgeries, travel insurance amongst others. It is a plan that is mostly targeted at the younger demographic, which is why it comes at such an affordable rate. There is also the Couples plan which is targeted at people who are into serious committed relationships. One of the unique things about the plan is that it offers free pre-marital medical tests like blood group, genotype, etc. After 18 months on this plan, subscribers are entitled to fertility tests and also get access to maternity cover. The Life plus Plan which has a wider coverage compared to the two plans I just mentioned, offers

extended benefit of annual wellness tests amongst others. The Boss plan provides access to some of the best hospitals in the country while the International plan takes care of individuals who travel a lot and would want to access health care whilst abroad. It also includes emergency air evacuation outside the country. After looking at the retail segment of the economy, we came up with these plans so that we can cater to each personâ&#x20AC;&#x2122;s healthcare needs depending on what stage of life they are at. Also, we looked at the different plans for Small and Mediumsize Enterprises (SMEs) in ways they can afford it so that their staff can be productive one hundred percent.

There have been insinuations that hospitals discriminate against HMO enrolees. The perception is that they treat patients who pay out-of-pocket better than patients covered by health insurance plans. Do you agree with this? To be honest, what you just mentioned used to happen in the past; say five to seven years ago. Now, most hospitals have identified the financially stable HMOs who pay their bills on time and in full as contracted. The reason it happened in the past was that some HMOs were in the habit of defaulting on payment of the claims and capitation fees due to the hospitals.

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

When they do pay, they arbitrarily slash the hospitals’ fees. However, the pressure on non-performing HMOs from the ever vigilant press and the regulator (Nigerian Health Insurance Scheme), has been huge and this has forced a change of attitude. Now hospitals prefer patients with HMOs that pay promptly. I can confidently say that all hospitals working with Avon HMO give preferential treatment to our enrolees and the reason is because we pay as and when due. The responsibility is on corporate organizations and individuals to do due diligence with the hospitals before signing on to any HMO.

Beyond paying claims and capitation fees when due, how else can HMOs ensure that enrolees get the best out of hospitals? I can only talk about how Avon HMO operates. We have a department called the Provider Services Unit which comprises of doctors and nurses that monitor our relationship with hospitals. We also have the Quality Assurance Department that is responsible for hospital accreditation; they inspect hospitals according to our standards before they are registered to our hospital network. In addition, they do random spot checks on hospitals to ensure that they keep to the agreed standards even after accreditation. We also utilize disease management frameworks as well as drug formularies. These are reviewed periodically and all the hospitals who are with us abide by them. With our disease management

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

frameworks, diseases or

individuals

with

specific

conditions are identified in order to make planned proactive care available, as part of a holistic preventive approach towards healthcare. We do this by tracking the performance of every individual’s care with hospitals, receiving feedback on their performance and then interacting with the individuals involved to ensure patientcentred care is achieved. In addition, we run drug formularies, which include lists of prescription drugs, both generic and brand name, used by practitioners to identify drugs that offer the greatest overall value. The formularies are monitored by in-house professionals (Doctors, nurses and pharmacists) as a cost-effective and efficient way to monitor what medication is being provided to each enrolee when they receive care in partner hospitals.

Universal health coverage remains a key deliverable for most countries including Nigeria. Stakeholders have said that it calls from collaborative efforts between the public and private sectors. What are Avon’s contributions towards achieving this objective? Universal health coverage is the dream of every country but only a few countries like Sweden and Netherland have achieved the feat. Bringing it home to Nigeria, we can only achieve UHC with the appropriate measure of political will. We need to put in place an efficient and effective network of healthcare facilities to meet the needs of the populace. Much still needs to be done. Bringing it down to the HMO space, I think

all operators, and not just Avon, need to take a critical look at the attendant issues to make the industry more efficient in order to attract foreign and local investors into the sector. Remember that one of the core responsibilities of HMOs is enabling accessibility to quality and affordable healthcare which is also a key component of Universal Health Coverage. So, by simply doing our jobs better, HMOs will be contributing in no small measure towards the actualization of the UHC. On Avon’s part, we are and we will continue to preach the importance of healthcare and why it is important that people invest in their own health the way they invest in education and accommodation because it strengthens the ecosystem. We are also working with other stakeholders in the health sector to pass the right laws that will empower and equip the regulators to do what is right always.

Finally, taking a bird’s eye view of the happenings in Nigeria’s health ecosystem, what would be your assessment of the industry? Let me start with my primary constituency. The NHIS, our regulatory body, has done very well in providing health cover for public civil servants at the federal level

and they deserve commendation for that. However, it must be said that penetration at the private sector level has been poor. In total, we have less than 10 percent of coverage in the country today and the bulk of that is from the public sector. So, we need to ramp up the numbers. Then, there is the issue of healthcare financing. The fact is that government expenditure on health is grossly insufficient and simply cannot meet the health needs of the country’s growing population. The Minister of Health did promise to renovate 10,000 Primary Healthcare Centres and that is a very bold, laudable move. Still, we will achieve more if both the private and the public sector collaborate. It’s time we stopped seeing health as a social investment and approach it as a business that is worth investing in. We cannot continue waiting for government. In America, healthcare is probably one of the biggest business sectors and Nigeria should be no different. There are bountiful opportunities in the health sector for investors and if the right incentives can be put in place, people will invest in any venture that will give them good returns.

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

Chapter 11

Nigerian Health Insurance Scheme: Issues, Prospects and Potential

he National Health Insurance Scheme was set up by Decree 35, of 1999 (now Act 35) operating as Public Private Partnership and directed at providing accessible, affordable and qualitative healthcare for all Nigerians. Health Insurance can be defined as a system of advance financing of health expenditure through contributions, premiums or taxes paid into a common pool to pay for all or part of health services specified by a policy or plan. Act 35 of 1999 which established National Health Insurance Scheme.

Anthonia Obokoh

The Scheme started its operation under the National Health Insurance Scheme Act, Cap N42, Laws of the Federation of Nigeria, 2004, aimed at providing easy access to healthcare for all Nigerians at an affordable cost through various prepayment systems.

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

Benefit of the Scheme among others is to ensure that every Nigerian has access to good healthcare services, ensure equitable distribution of healthcare costs among different income groups, protect families from the financial hardship of huge medical bills, ensure efficiency in healthcare services registering health maintenance organisations and healthcare facilities under the Scheme among others The scheme is a pre-payment plan where participants pay a fixed regular amount. The amount/funds are pooled, allowing the Health Maintenance Organisations (HMOs) to pay for those needing medical attention. It is primarily a risk sharing arrangement which can improve resource mobilisation and equity. NHIS is to provide social health insurance in Nigeria where health care services of contributors are paid from the common pool of funds contributed by the participants of the Scheme. NHIS also regulate private health Insurance operated by HMOs with 60 HMOs currently registered under the scheme. Health Insurance is social security system that guarantees the provision of needed health services to persons on the payment of token contributions at regular intervals. State of the health insurance in Nigeria has had many challenges in the health insurance sector, compared to peer countries in Africa (Ghana and South Africa) the growth of health insurance. Sadly, 19 years since the establishment of the scheme in Nigeria, nothing significant has been achieved. With only 1% of the total 180 million Nigeria populations enrolled under the scheme. The scheme continues to witness somersault in policies, ineffective operational guidelines, corruption, inefficiency and bureaucracy of the registration to mention just a few. Regrettably, the quality of care received under the scheme is exceedingly questionable with accusing fingers pointed to the major stakeholders which include the NHIS, HMOs and the Hospitals. This has in turn left out many people who may require these services but lack the necessary awareness and education to get a health care insurance for themselves and their families. The NHIS mode of enrollment still remains poor with users been enrolled at place of their work as a federal government employee or as a staff of any agency that joined the scheme despite the introduction of a new policies in 2012 to co-opt non-formal sector into the programme through such initiatives as community- based social health insurance scheme, tertiary institution social insurance scheme, public-private partnership social insurance

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

scheme and vulnerable group social health insurance scheme. The initiative introduced was to increase enrollment but since the government does not make it compulsory has resulted in haphazard implementation of the programme. Another major setback is the issue of corruption and other related offences with different principal actors trying to undermine accountability in the scheme and also protect their own stake in different HMOs. Corruption is widespread to the point that they cannot even perform statutory roles of supervising the HMOs. On the part of HMOs, they are so powerful and notorious to the point that their responsibilities of serving as middlemen between the government and hospital is now jeopardy with different issues like non-payment of capitation, non-payment of fee for service for several months, poor quality response to enquiries and poor management. Hospitals also are other players that sabotage the scheme in their own way. Some hospitals in order to maximize gain, capitalised on the fact that branded prescriptions are not allowed in NHIS prescription, to stock cheap and substandard drugs for the patients, they also recruit HMOs staffs are not well skilled and they always tend to see people who have chosen to insure their health lower to those who did not want to. Since they pay lower and enjoy insurance advantages. Hence, they tend to concentrate on them in a personal manner compared to others. The sustainability and viability of a countryâ&#x20AC;&#x2122;s economic and social growth depend largely on vibrant healthcare sector of that nation hence the need for federal and state government to make health insurance compulsory and affordable to the citizenry, this can be achieved by improved funding of the sector and subsiding the premium paid. Other steps that can be taken include, more supervisory and sanctioning of erring HMOs and Hospitals, accountability and more advocacy to demystify the myth already established in the minds of the people towards health insurance scheme.

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

Chapter 12

Policy Context of The Health Sector Omosomi Omomia

igeriaâ&#x20AC;&#x2122;s health sector operates in the context of a number of policy frameworks and within a policy environment that is subject to internal and external influences. Extant health policies (at the state and federal level) and legislation, and international declarations and goals to which Nigeria is a signatory have shaped the direction of the health sector since independence. In recent times, such policy statements as articulated in the targets of the Millennium Development Goals (MDGs), the Abuja declaration signed in 2002, the Ouagadougou Declaration on primary health care, the Paris Declaration on Aid Effectiveness, the 7-Point Development Agenda, as well as the more recent National Strategic Health Development Plan (NSHDP) are the most prominent. However, National Health Act, which was signed into law in December 2014, is the major single legislation which has given Nigeria a definite body of law that governs health care delivery in the country. The act

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

describes the national health system and defines the roles and responsibilities of the three tiers of government and other stakeholders. Prior to presidential assent, there was no health legislation describing the national health system and defining the roles and responsibilities of the three tiers of government and other stakeholders in the health sector. This engendered a situation where federal, state and local governments often had conflicting or overlapping rules. It took almost half a decade to get the National Health Act through the law making process. The final product has been described as having the potential of addressing some of the major challenges the health care sector in Nigeria faces. It addresses the problem of finance (as regards public owned health facilities), access to health care for the poorest, addresses issues of quackery and substandard health

care providers. The act provides a framework for the regulation, development and management of the national health system and sets standards for rendering health care in the country. The document which is called National Health Act is itself divided into seven parts:

a. 50% will be used for the provision of basic minimum package of health services to citizens, in eligible primary/or secondary health care facilities through the National Health Insurance Scheme (NHIS);

• PART I- Responsibility for health and eligibility for health services and establishment of national health system

b. 20% shall be used to provide essential drugs, vaccines and consumables for eligible primary health care facilities;

• PART II- Health establishments and technologies

c. 15% shall be used for the provision and maintenance of facilities, equipment and transport for eligible primary healthcare facilities; and

• PART III- Rights and obligations of users and healthcare personnel • PART IV- National health research and information system •

PART V- Human resources for health

• PART VI- Control of use of blood, blood products, tissue and gametes in humans • PART VII- Regulations and miscellaneous provisions

Each section is designed to address a key element of the biggest health system in Africa. To improve finance for government owned health care institutions, the Act establishes a Basic Health Care Provision Fund to be financed from Federal Government Annual Grant of not less than one

per cent of its Consolidated Revenue Fund, grants from international donor partners and funds from other sources. The fund is to be distributed as follows:

d. 10% shall be used for the development of Human Resources for Primary Health Care; e. 5% of the fund shall be used for Emergency Medical Treatment to be administered by a Committee appointed by the National Council on Health. There are strict restrictions surrounding the disbursement and utilization of the funds. Specifically, certain conditions must be met before funds can be disabused. However, the Act prohibits the National Primary Health Care Development Agency from disburse funds to local government health authorities that do not justify the use of previously allocated funds. It also makes it clear that state or local governments that have failed to contribute their counterpart funding as prescribed by the act should not receive funds. Also in the

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

same vein, states and local governments that fail to implement the national health policy, norms, standards and guidelines prescribed by the National Council on Health are to be starved of their share of funds that ordinarily would have been made available by the Basic Health Care Provision Fund.

To engender quality in the system, the Act encourages any person to lay a complaint about the manner he or she was treated at health facilities. The Minister or Commissioner or any appropriate authority is mandated to establish a procedure for the laying of complaints within its area of responsibility.

Overall, the act mandates the National Primary Health Care Development Agency to develop appropriate guidelines for the administration, disbursement and monitoring of the fund with the approval of the Minister.

At the center of the law is the user of the health care system. While some of the provisions of the law guarantee care for the poorest of the population, other aspect protect the generality of the population against abuse or deprivation in the face

But apart from funding, the act seeks to raise standards in the sector, thus increasing the risk quacks face. It prohibits any person, entity, government or organization from establishing, constructing, modifying or acquiring a health establishment, health agency or health technology; increasing the number of beds in, or acquires prescribed health technology at a health establishment or health agency and so on without obtaining a Certificate of Standards. As part of effort to resolve the inadequacy of qualified manpower, it charges the National Council on Health to develop policy and guidelines for, and monitor the provision, distribution, development, management and utilization of human resources within the national health system. This includes facilitating and promoting adequate distribution of human resources; providing appropriately trained staff at all levels of the system to meet the populationâ&#x20AC;&#x2122;s health care needs; and effective and efficient utilization, functioning, management and support of human resources within the system.

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA

of emergency. The Act prohibits a health care provider, health worker or health establishment from refusing a person on emergency medical treatment for any reason whatsoever, making any person who contravenes this provision guilty of an offence and liable to a fine of N100,000.00 (One Hundred Thousand Naira) or to imprisonment for a period not exceeding six months or both. Many other offenses carry penalties of different degrees. A section states that for the purpose of transplantation, there shall be an independent tissue transplantation Committee within any health establishment that engages in the act and practice of transplantation as prescribed. Only a registered medical practitioner or dentist may remove any tissue from a living person, use tissue so removed for any of the purposes stated in this Bill or transplant tissue so removed into another living person. Only a registered medical practitioner or dentist, or a person acting under the supervision or on the instructions of a medical practitioner or dentist, may administer blood or a blood product to, or prescribe blood or a blood product for, a living person.

The Act bans public officers from sponsoring medical check-up, investigation or treatment within and outside the country at public expense except in exceptional cases and on the recommendation and referral by the medical board and proper approval by the Minister or Commissioner of health. It states that without prejudice to the right of any Nigerian to seek medical check-up, investigation or treatment anywhere within and outside Nigeria no public officer of the government of the Federation or any part thereof shall be sponsored for medical check-up, investigation or treatment abroad at public expense except in exceptional cases on the recommendation and referral by the medical board and which recommendation or referral shall be dully approved by the Minister or the Commissioner of health of the state as the case may be.

But there have been a number of concerns raised over the bill chief among them have been the treatment of health professionals across the divide. There were initial objections by some classes of health workers that the bill gives a lot of preference to medical doctors and also gives more powers to the minister of health. Also because of the level of rivalry between states, local government and the federal government, the workability of the revenue distribution mechanism engendered by the act through the Basic Health Care Provision Fund has been questioned.

INSIGHTS FROM THE LEADING HEALTH MAINTENANCE ORGANISATIONS IN NIGERIA