IMPLEMENTATION MANAGEMENT by Rova College of Healthcare Executives

Hea

t iv

a Colleg ov

th care xecu E

IMPLEMENTATION ..state supported health insurance schemes Getting it Done - UHC

VOLUME 13

What is your quality - cost strategy Simple solutions to complex problems Leapfrogging health systems Save One Million Lives PforR Innovative philanthropy

N1500

THE STONE AGE DID NOT END BECAUSE OF LACK OF STONES

T H IN S U R A AL

N SCHEME CE

TIONAL H NA E

Supported by

45 SPOTLIGHT: IMPLEMENTATION MANAGEMENT STATE SUPPORTED HEALTH INSURANCE SCHEME

Getting it Done

Developing a sustainable Health Insurance System in Nigerian

20 32

The Adaptive Diamond Approach to Implementation Management

The Success of a “State Supported Health Insurance Programme”

48 58

Healthcare Management Review Volume 13

PAGE

007

HEALTHCARE MANAGEMENT CONFERENCE 2016

Public Private Partnership in Health Nigeria

Creating New Quality & Efficiency Frontiers and Reversing Medical Tourism A STRATEGIC MEETING BETWEEN HEALTHCARE STAKEHOLDERS, POLICY MAKERS AND INVESTORS 22-23rd March, 2016, Nicon Luxury Hotel, Abuja-Nigeria

es t iv

th care xecu E

Federal Ministry of Health

Hea

Infrastructure Concession Regulatory Commission

a Colleg ov

THE PRESIDENCY

WORKING PARTNERS

Rova College Healthcare Executives Executive Education

For Further information contact the conference coordinator 08087504372, 08033247431 rova_healthmgt@yahoo.com, pppsinhealthnig@yahoo.com 08035949524 bolaolowu2004@yahoo.com

A Hole at the Bottom of the Sea

Universal Health Coverage

What is Your Quality-Cost Strategy?

Recalibrating Nigeria Healthcare Delivery for the Future

Leapfrogging Health System in Emerging Economies

Saving One Million Lives Program for Results (SOML PforR)

102

112 Healthcare Management Review Volume 13

PAGE

009

The following organizations has demonstrated their commitment to implementation of State Supported Health Insurance Schemes

T H IN S U R A AL

N S CE CHEM E

TIONAL H NA E

FEDERAL MINISTRY OF HEALTH NIGERIA

hfn ENGAGEMENT

ACCESS

QUALITY

PMG

MAN

Pharmaceutical Manufactures Group of Manufacturers Ass. of Nig. (PMG-MAN)

Healthcare Management Review Volume 13

PAGE

011

The only limits of power is the bounds of belief Harold Wilson

y any measure, you have more power than you think. Don't suffer from the fear of trying. If you have never sustained a set-back, I suspect it's because your aim has been too low. Too often, what prevents us from attempting more is in the invisible images in our minds. This is what I call the tendency to focus on the 4Fs: faults, ď&#x20AC;&#x201A;aws, foibles, and failure. Should this be the case, your last frontier is not outer space, but inner space. It's you yourself and the artiď&#x20AC; cial barriers that you've established that limits your potential.

EDITOR IN CHIEF Emmanuel C. Abolo

@rovahmr www.facebook.com/rovahealthmgt www.linkedin.com/in/rovahmr

SENIOR EDITORS Godwin Odemijie Moji Makanjuola INTERNATIONAL AFFAIRS BUREAU CHIEF Vicky Akai Dare DIRECTOR - EDITORIAL OFFICE Nkechi D. Abolo STAFF GRAPHIC DESIGNER

James David Chinedu Iroegbulam SCRIPT EDITOR

Tinuke Obikoya RCHE FACULTY ADVISORS

Prof. Rowland Ndoma-Egba Prof. Femi Adebanjo Prof. Okey Mbonu Dr. Ibrahim Wada Dr. Emmanuel C. Abolo (Jnr) Dr. A Dutse Dr. Kabiru Mustapha Barr. Charles Okei Mr. Fidel Anyanna Kemi Lawanson CREDITS

Marketing Partner

Nigeria Health Insurance Scheme (NHIS) Health Strategy and Delivery Foundation World Economic Forum Mr. Olufemi Akingbade Dr. Leke Petan Dr. Ibrahim Kana Aaron J. Shenhar Dov Dvir Susan Brik Clayton M. Christen Blake Mykoskie

VENTOLITE MARKETING INTâ&#x20AC;&#x2122;L. LTD.

Healthcare Management Review Volume 13

PAGE

013

E D I TO R I A L

GOING THE

DISTANCE

tate Supported Health Insurance programmes by definition is unique. It represents a new experience, addressing an old problem with a new constellation of management challenges. It is a multidimensional strategic concept that requires deep understanding of complex dynamic adaptive systems. It needs an extensive system integration, together with the development of a new combat doctrine. Various elements make up the State Supported Health Insurance Programme which is built on an evolutionary form in which additional systems are generally appended. It has to be constantly modified, improved, and components added to existing formats. You never build it into an array from the scratch. The State Supported Health Insurance Scheme (SSHIS) is typically structured under an umbrella organization – the State Health System with financial, logistics, and legal issues and is responsible for controlling offices of the subsystem that make up the programme. According to the adaptive approach to implementation, SSHIS programmes are not just a collection of activities that need to be completed on time. Instead, programmes that are 'business' related that must deliver business results: quality, affordable and accessible healthcare. They involve a great deal of complexity and must be managed in a flexible adaptive way. Planning is not rigid, fixed or shaped once and for all; instead it is adjustable and changing, and as the programme moves forward, replanning is often appropriate or even unavoidable. And the implementation management style must adapt to the specific requirement. Leaders of array programmes like SSHIS programmes must be aware of the social and environmental impact of their programme and take into account the

Healthcare Management Review Volume 13

PAGE

016

views of political decision makers. No SSHIS programme will survive if it loses its political support and trust. Defining, planning and managing an SSHIS programme is a complex managerial and organizational undertaking. A SSHIS programme is not a repetitive duplication of an assembly, rather, it requires a new set of skills and a different level of attention to the system architecture You need to build a system approach and system thinking skills. This means seeing the SSHIS as a whole and not only as a collection of parts and subsystems. It also means taking a top-down view, which starts with a vision of the entire system goal and how it will serve the enrollee and providers. You must learn to make decisions at the interface of disciplines and subsystems and often you sacrifice local optimization of one or more parts to maximize total system optimization. The SSHIS programme is a part of the strategic management of the state healthcare system and should be accessed based on its contributions to the overall health outcomes and not only on ability to meet time, budget and performance goal. The success should reflect the short, middle and long term objectives with time frames in mind. It should be primed to change the bases for providing quality, accessible and affordable healthcare. It should create adjacent possibilities and on the long run new muscles for the state healthcare system. It requires a new healthcare business model, building new operational lines that help run an efficient health system. Unless we can make this happen, it is not going to matter.

Healthcare Management Review Volume 13

PAGE

017

“Markets that do not exist cannot be analyzed.” What marketing/advocacy technique will you use to create “Buy-in” for State Health Insurance Scheme / Prepaid healthcare programme.? Start with small trials, and play with ideas that do not threaten the existing organizational establishment but create trust. Use judgment and intuition to create ﬁrst prototype and test them quickly to obtain customer feedback as soon as possible, only then can you ﬁnalize product characteristics and freeze requirements.

TOYOTA'S LAUNCH VEHICLE WAS A CORONA, NOT A LEXUS.

The most essential innovations begin with simplicity and accessibility. Toyota made a name for itself in the United States ďŹ rst with a Corona; the far more ambitious Lexus came later.

INTERVIEW

Mr. Olufemi AKINGBADE Ag. Executive Secretary/CEO National Health Insurance Scheme

Healthcare Management Review Volume 13

PAGE

020

“

Universal health coverage represents one of the key targets of the post 2015 SDGs. It addresses equity, represents a giant eﬀort at sustainable development and a major health policy goal.

”

Healthcare Management Review Volume 13

PAGE

021

Extracts of HMR Interview with Mr. Olufemi Akingbade - Ag. Executive Secretary/CEO National Health Insurance Scheme. Highlighting the business case for State Supported Health Insurance Schemes and Innovative Financing in the face of Current Fiscal Constraints. He also provided the insights into adaptive healthcare models emphasizing quality and service delivery as the trust prescription for Health Insurance.

What is the Role of NHIS in ﬁxing, the Nigeria Health System.

the potential to correct the disproportionate distributional inequity that favours the urban areas.

The Nigerian Health System, though with marginal improvements in the last few years still performs poorly. Some of the issues with the system include, inefﬁcient funding, service delivery issues, including inequity in service distribution both in quantity and quality, inadequate human resources for health; poor oversight due mainly to constitutional provisions; and others.

The NHIS is working with other relevant stakeholders to ensure the availability of capital at single digit interest rates to intending practitioners to be able to access these funds. This will mainstream private sector participation in service delivery, ensure high standard of care and improve distribution of health facilities

The NHIS, as the major health financing institution also saddled with the mandate of achieving UHC has a significant role to play. First, by generating the required demand for healthcare, it will provide the necessary stimulus for the development of the supply side of the system. The private sector, driven by profit will be encouraged to set up health care centres, when they are sure of generating the clientele to be profitable. This has

Access to quality health care services is an important intermediate goal and performance indicator of a health system. The core objective of NHIS is to provide this access to all Nigerians. And in doing this, it not only improves the systems equity demands (vertical and horizontal) but contributes to the overall achievement of the key health system goals of improved health status, consumer satisfaction and ﬁnancial risk protection.

Healthcare Management Review Volume 13

PAGE

022

What are the Speciﬁc components of UHC at the National and State levels. Universal health coverage represents one of the key targets of the post 2015 SDGs. It addresses equity, represents a giant effort at sustainable development and a major health policy goal. Achieving UHC however, has its own challenges. This includes the structure and state of the health system, political, technical and ethical issues. Every systems tends to address UHC by looking at its various components/dimensions. These components include: Ÿ

Population coverage: increase the share of the population that beneﬁts from pooled ﬁnancing.

Cost coverage: reducing the amount of out-ofpocket payments through more ﬁnancing with

pre-paid insurance schemes and taxation. Ÿ

Service coverage: Expansion of the scope of services that are paid for from pooled ﬁnancing sources.

Due to resource constraints facing most systems, more cost effective incremental approaches are usually advocated. A system can decide within the constraints of its resource availability to achieve universal population coverage with basic cost effective service. It will later work towards deepening the beneﬁt base as its resources increase. Universal population coverage improves cost coverage by reducing the level of out of pocket payment in the system. This is further improved by deepening service coverage. Universal health insurance provides the convergence platform for these three components. Healthcare Management Review Volume 13

PAGE

023

Achieving UHC in Nigeria through Universal health insurance in Nigeria throws up challenges that require ingenuity to address them. Health in Nigeria is on the concurrent list in the constitution, giving states power to legislate on health, thereby creating special oversight and stewardship challenges.

country. The NHIS will integrate these pools through an equalization or equity funding mechanism. If this is achieved, the states will now carry out the implementation roles, while NHIS will perform resource mobilization, equalization and regulatory and promotive functions.

Currently, health insurance in Nigeria follows a fragmented approach with everybody doing what seems right or proďŹ table to him. The only structure that has a large pooling system is the NHIS with its formal sector programme, using the social health insurance approach. The HMOs are providing primary insurance using the private health insurance approach. Some communities are implementing disparate community based health insurance schemes that are often unsustainable. There has not been any deďŹ nite move towards UHC as has been done in other countries.

What Innovative strategies and blues ocean thinking are you applying to fast tract UHC

To address these challenges, the NHIS is implementing a subtle system reforms aimed at creating an integrated pooling system as a route to achieving UHC. In this reform, the NHIS is encouraging and guiding states to establish mandatory health insurance schemes in their domains. If achieved, there will be 37 pools in the

The Scheme in its quests to expand coverage has designed, certain programmes that will fast tract the achievement of UHC, most recent is the National Mobile Health Insurance (NMHI) which had been launched and currently undergoing pilot in Lagos before cascading it nationwide. The cost is moderate and affordable to the target group. This programme when in full stream will certainly revolutionize the up-take of health insurance in Nigeria. The Scheme is also proposing the introduction of innovative ďŹ nancing options to quickly achieve universal health insurance coverage as the route to UHC. Some have been mentioned in earlier sections.

Healthcare Management Review Volume 13

PAGE

024

The NHIS is implementing a subtle system reforms aimed at creating an integrated pooling system as a route to achieving UHC. In this reform, the NHIS is encouraging and guiding states to establish mandatory health insurance schemes in their domains. If achieved, there will be 37 pools in the country. The NHIS will integrate these pools through an equalization or equity funding mechanism. If this is achieved, the states will now carry out the implementation roles, while NHIS will perform resource mobilization, equalization and regulatory and promotive functions.

What Strategies are you applying to finance UHC and efficiency in the utilization of funds? No doubt, sustainable financing is central to achieving UHC. This is more important now given the prevailing poor state of government revenue base occasioned by the global economic meltdown. There is need to reduce excessive dependence on government for funding for achieving UHC. Part of our strategy to finance UHC is to engender the requisite political will from the Government, especially the central government towards implementing innovative financing reforms as highlighted earlier. Also buy-in by the States will further provide some financing at that level. We rely on the Federal Government for continuous funding for its workers based on the present arrangement while at the same time efforts are on to get the State buy-in in-spite of the prevailing fiscal fund allocation constraints. The State buy in will no doubt scale up population coverage of Nigerians. An opportunity has been presented by the NHAct by making 0.5% of the consolidated revenue for the provision of Basic Healthcare Package for Nigerians. The Scheme is exploring other funding mechanisms,

such as the introduction of a telecoms tax (1k/sec), an aviation tax for air travellers, increasing the VAT and dedicating the proceeds for UHC. The pursuit of efficiency has been at the core of the NHIS operations. The service delivery model, the provider payment mechanisms and tailoring of the benefit package to the needs of the people rather on willingness and ability to pay are strategies to optimize the efficiency of the system. To further improve the efficiency of the system, the scheme is collaborating with NPHCDA to address the supply side causes of inefficiencies, such as wastages and allow the private sector to drive service provision for UHC. Are there Local and International collaborations and alliances supporting UHC technically? Yes the Scheme has both local and international collaborators. International Finance Corporation, Pharm Access, Melinda and Gate Foundation, JLN, PATHS2 etc. are supporting NHIS technically and financially (though not direct funding) towards the achievement of UHC.

Healthcare Management Review Volume 13

PAGE

025

There is need to approach implementation of healthcare as flexible and adaptive, one that will enable healthcare systems deal with the dynamics of change, complexity and uncertainty in the healthcare systems

To reduce funding inefficiency and duplication of efforts, what will be the framework for basket funding? A basket fund is a mechanism for pooling funds from various sources, typically governments, donors and the private sector to support priorities and ensure adequate resource allocation for agreed upon program areas. The NHIS in the last seven years has partnered with about thirteen States through a basket funding arrangement in the implementation of maternal and child healthcare programme (NHIS-MDGs/MCH). In this project funds from the MDGs Office and the States counterpart are pooled for the target group. This ensure uninterrupted provisions of services. This approach has been implemented with a positive outcome. Also, the NHIS through the instrumentality of it enabling law is proportion the establishment of a National Vulnerable Groups Fund to warehouse all funding for universal health insurance as the vehicle for UHC. This fund will be allocated through the States schemes to target the poor and the vulnerable in Nigeria, who cannot afford to make contributions into the health insurance pools. Do we have a strong provider network to maximize the impact of exponential growth in the number of enrolees? The NHIS has over the years built a strong network of providers with a base of 10,232 Healthcare providers across the country. These are providers that have met minimum quality standards set by the Scheme.

Accreditation of more numbers is ongoing. How do you intend to encourage more private providers to join the Scheme and expand the provider platform? There are quite substantial number of providers on the waiting list for inspection and possibly accreditation. As the UHC vehicle takes off with increasing enrolee base, it is envisaged that more will be brought into the system to provide the services. This is to enable them be able to get the right numbers to be able to make good returns on their investments. What are the levels of uncertainty and complexity involved in UHC? The pursuit of UHC is always complex and requires a coordinated approach, strong political drive and good technical design. Achieving UHC usually takes a long time, the shortest being Costa Rica with just 20 years. In a developing nation like Nigeria, the political dynamics may be a very important challenge. The structure of the economy – how formal or Informal the economy is may be another challenge to achieving UHC. As an economy grows and formal structures for business are set up, it tends to make it a lot easier to achieve UHC especially through universal health insurance. This is really a challenge in Nigeria with the informal economy accounting for close to 70% of the economy. The large informal sector present a serious challenge in terms of numbers and also difﬁculty in identifying and reaching the most vulnerable citizens Healthcare Management Review Volume 13

PAGE

026

The pursuit of UHC is always complex and requires a coordinated approach, strong political drive and good technical design

will certainly affects the interventions for the vulnerable programmes. Also working through the vested interests towards the UCH especially when it comes to reduction and fixing of prices particularly with private healthcare providers. Worsening solidarity among the people particularly in areas with insecurity challenge, implementing some programmes in those areas comes with immense difficulty. The State Supported Health Insurance Schemes (SSHISs) is one of the platforms for accelerating UHC, what is the economic and financial model for SSHIS in the face of fiscal constraints in the States? NHIS is to set up an equity funds to catalyse cross subsidization through an equalization mechanism to be defined. The states will mandate all able to pay to contribute to their pools and those not able to pay will be paid for. The states are also asked to set aside a mandatory percentage of their consolidated revenue into an equity fund to be matched by that from the NHIS. This is for paying the contributions for the poor and vulnerable persons in the states. In addition the States will be encouraged to channel the sources of funding existing free health programmes into the SSHISs.

health insurers to provide this for them. Therefor the State social health insurance schemes should be the primary health insurance provider for all in the state. In the absence of technical capacity by the States what role will NHIS and HMOs in the emerging architecture The Scheme will play the following roles in the emerging architecture: Ÿ

Coordination for SSHIS shall be continuous

Support in the drafting of legal frame in each State

Development of beneﬁt package and their costing

Development of operational documents

ICT Infrastructure support and deployment to the States

Capacity Building for SSHISs

Promotion and Sharing of best practices

In the guidelines for States, they are at liberty to decide their purchasing arrangements. However, the NHIS encourages States to tap from the wealth of experience of the HMOs as it relates to purchasing. Thus states can assign deﬁned roles to the HMOs to perform for them.

The present enrolees proﬁle for the formal sector in the various States is also a source of funding. In the development of the enabling laws setting up the States' health insurance schemes, NHIS insists that it makes participation mandatory for everybody in the state. Those who need higher beneﬁts could contact the Private Healthcare Management Review Volume 13

PAGE

027

“

UHC is not the mass provision and availability of any care but the mass provision through diverse channels affordable, accessible and quality health service which meet the needs of the people. Without good quality of service the willingness to pay is low.

For disadvantaged States and other options that can deliver care to the poor using the principles of health insurance. Ÿ

All States are expected to beneﬁt from the equity funds intended for the Q1 and Q2 and other targeted populations. However they must meet up with the minimum requirement set up by the Scheme to beneﬁt. It is important to note that the concept of disadvantaged states should not really be a major issue. Whether advantaged or disadvantaged, every state has a duty to provide health care for its citizens. The health insurance option represents the most sustainable, transparent and affordable mechanism to drive the health policy goals of any state. It has been proven in other countries. The only thing is that states are asked to provide what they can afford to pay for.

Number of states that have enacted a legislation for implementation,

Number of States with set up of a SSHIS Agency,

How many states have put down funds to beneﬁt from the equity funds

Considering quality as the main driver of trust in UHC, how do you encourage and ensure quality at the provider end ?

The National Health Insurance Scheme prior to engaging HCPs in its network ﬁrst inspect the facilities to ensure that they meet the basic minimum standard to provide services for the enrolees. We also ensure that the personnel required for each level of care are met before accrediting such facilities. The current arrangement setting up NHIS is a PPP platform with each of the stakeholders having a clear roles to play. The Scheme has always ensure that the HMOs carry out quality assurance at the facilities serving as the eyes of the Scheme at the facility level.

In addition to this NHIS also uses third party arrangement to monitor quality and carry our survey on our enrolees to get feedback on the quality of services received by them.

What are the experiences from the leading States on SSHISs especially the Kwara, Lagos and Ogun State?

Some of the revelations and experiences show: Ÿ

That for CBHI to be successful, there must be some level of subsidy,

That targeting the poorest of the poor is critical rather than the blanket subsidy applied in Kwara,

How do you determination of the success of SSHISs

In the interim and for NHIS, the key success drivers at this initial stage will be:

”

Can we institutionalize, quality improvement mechanism? Yes we can institutionalize quality improvement mechanism and this is being worked on at various levels. The FMOH is working towards establishing a

Healthcare Management Review Volume 13

PAGE

028

centralized National quality agency. This will be a welcome development Ÿ

What quality data should be measured and reported?

Some of the quality data that should be measured include the following: Ÿ

Waiting time at the point of accessing care,

Personnel: Doctor patient ratio at the facility level,

Environment of the facility,

How many patients are seen by the providers and how many actually comes back for follow up or get well in terms of outcome

Consumer satisfaction

Can credit ﬁnancing for micro, small and medium healthcare providers be made available through facilities such as CBNMSMEDEF? Yes it can and the Scheme is already looking in that direction and has already began to engage such institution in that direction .What other ﬁnancing windows are available to support the acquisition of new technology by providers? Through hospitals capital investment programme for the facilities. This is actually an opportunity for Financing Institutions to take advantage of but at one digit interest rate and perhaps with moratorium of time before repaying back with NHIS guarantying such loans.

It must however be stated that universal health insurance is the only sustainable, affordable and cost effective mechanism that have been used by those countries that have achieved UHC. Healthcare Management Review Volume 13

PAGE

029

Developing a sustainable Health Insurance System

in Nigeria State Supported Health Insurance Scheme

he State Supported Health Insurance Programme (SSHIP) represents one of the outputs of the reform process, and aims to put the state in the driving seat of health insurance implementation in Nigeria. It hopes to provide a platform for constructive engagement between the states and NHIS, to efď&#x20AC; ciently perform health system oriented roles and contribute to the overall achievement of its goals. Healthcare Management Review Volume 13

PAGE

032

The signiﬁcance of this is clear, in the perspective of the challenging but achievable goal of ensuring that all our citizens have guaranteed access to needed healthcare services, irrespective of their socio-economic status, especially with its implications on productivity and economic development. As we all will appreciate, health is a major productive asset and has a positive correlation with economic development. Poor health can trigger a vicious cycle that has the potential to drag down a nation's wellbeing, as ill health engenders poverty, which in turn perpetuates ill health. Thus, any nation worth its name takes the health of its citizens very seriously. Consequently, in most poverty reduction efforts, health issues have become central, if such poverty alleviation activities are to make any meaningful impact. Perhaps, this realization is captured more succinctly in the Millennium Development Goals (MDGs), NEEDS, SEEDS and other poverty reduction agenda of governments in Nigeria. In the post-MDG era, a major developmental issue at the front burner is

the concept of Universal Health Coverage (UHC), which has gained national and international appeal recently, and is currently being pushed up in the national and global policy agenda. The concept is all about access (both ﬁnancial and geographic), equity and qualitative healthcare services. NHIS remains the main hub, in Nigeria's focus on the achievement of UHC. In that process, the Scheme has implemented the various programmes since its ofﬁcial launch in 2005. These include, the Formal S e c t o r P r o g r a m m e ; t h e Te r t i a r y Institutions Social Health Insurance Programmes (TISHIP); the Community Based Social Health Insurance Programmes (CBSHIP) and the NHISMDG/Maternal and Child Health project, with varying degrees of successes and challenges. However, one key challenge has been the non-participation of States. As the objective of pursuing Universal Health Coverage became imperative, NHIS embarked on a process of reformation, re-engineering and repositioning, to be able to achieve this Healthcare Management Review Volume 13

PAGE

033

mandate. New and innovative programmes such as the Public Primary Pupils Social Health Insurance Programme (PPPSHIP) and the National Mobile Health Insurance Programme (NMHIP) are being introduced to enhance coverage. The Scheme is also reviewing and re-packaging its other existing programmes to address operational challenges and facilitate buy-in by stakeholders, especially the States. The State Supported Health Insurance Programme (SSHIP) represents one of the outputs of the reform process, and aims to put the state in the driving seat of health insurance implementation in Nigeria. It hopes to provide a platform for constructive engagement between the states and NHIS, to efﬁciently perform health system oriented roles and contribute to the overall achievement of its goals. I would like to reiterate the Scheme's readiness and commitment to ensuring the success of this initiative. Thus, NHIS will accord every state all the necessary support to perform its functions towards the realization of the UHC goal. We at NHIS are highly encouraged by the efforts of Kwara, Ogun, Enugu, Lagos and Delta

States in this regard. These states have demonstrated in clear terms their desire to provide easy access to healthcare for their citizens. We will continue to discuss the State Supported Health Insurance – concepts, operation modalities and prospects, in the light of the National Health Act and the quest for UHC. The speciﬁc objectives are to provide a common platform for the achievement of UHC, sensitize stakeholders on details and open up channels of collaboration to ensure synergy and efﬁciency of programme implementation. It will also provide us the opportunity to share lessons learnt from those states that have been on this course. It is important that, the NHIS, States and other stakeholder would have a clear understanding of the States Supported Health Insurance Programme, and chart a common course towards Universal Health Coverage in Nigeria.

Extracts of Address by Mr. Olufemi Akingbade Ag. Executive Secretary/CEO NHIS at a conference on implementing State Health Insurance Scheme

Healthcare Management Review Volume 13

PAGE

034

Objec ves

Ÿ To provide a mechanism for efﬁcient implementation of States’ health access

programmes. Ÿ Decentralize health insurance implementation to the States. Ÿ To rapidly expand coverage towards UHC. Ÿ To bring states into collective ﬁnancing of healthcare through health insurance. Ÿ To ensure uniformity in the design and implementation of health insurance across the

states.

Healthcare Management Review Volume 13

PAGE

036

States’ Supported Health Insurance at a

Glance Legal Framework

Ÿ First step is to deﬁne a law to guide implementation Ÿ Ensure the States’ laws align with NHIS Act and NHAct for seamless collaboration Ÿ Make health insurance mandatory for all. Ÿ Deﬁne clearly funding mechanism for coverage of those who cannot afford the premiums. Ÿ Ensure that all other insurance schemes/plans contribute to funds dedicated for the poor

and vulnerable Ÿ If states decide to use TPAs, it should clearly deﬁne their roles within the framework.

Healthcare Management Review Volume 13

PAGE

037

Governance and Administra on Ÿ Domicile Agencies in the Governor’s ofﬁce Ÿ Limit the number of components of administrative structure Ÿ Use Third party purchasers for efﬁciency and expertise. Ÿ Limit administrative costs. Ÿ Ensure data reliability and validity. Ÿ Plan for the use of

ICT infrastructure to reduce cost of administration and improve

effectiveness.

Funding Ÿ Equity funding vital to achieving pro poor coverage Ÿ Deﬁne alternative sources of raising funds Ÿ Community based ﬁnancing methods Ÿ Mandatory contribution from those able to pay Ÿ Explore other sources of outside funding – NHA, SOML,

NHIS, UHC fund, Donors Ÿ Health levies Ÿ Channel existing free health programs into SSHIS for efﬁciency

Healthcare Management Review Volume 13

PAGE

038

Benefit Package Ÿ Create cost effective benefit package Ÿ Use the basic minimum package as defined by the National Health Act (to be

determined by NHIS/NPHCDA) as the minimum Ÿ Basic minimum package need to address the local disease burden Ÿ Expand package based on resource availability Ÿ Carry out actuarial costing of beneﬁt package.

Providers engagement and selec on Ÿ Provider selection should ensure maximum access to services by beneﬁciaries Ÿ Integrate public & private providers in service delivery Ÿ Include Performance based methods in remunerating providers to promote efﬁciency Ÿ Enhance quality through provider accreditation and other quality assurance systems. Ÿ Give choice of providers to ensure satisfaction and drive quality

Healthcare Management Review Volume 13

PAGE

039

Target the poor Ÿ Ensure the poor are included in pro poor schemes. Ÿ Limit inclusion and exclusion errors to reduce leakages Ÿ Means testing may be expensive and the need for less expensive inclusion methods. Ÿ Community based, categorical(demographic) targeting mechanisms are adviced

Monitoring and Evalua on/ICT Ÿ Establish a robust M&E framework Ÿ Actively monitor the implementation of schemes. Ÿ Establish a robust and Integrated ICT infrastructure for data collection and

assessment Ÿ Use clear cut management, ﬁnancial and impact indicators to track progress Ÿ Establish collaborations on M&E with other Agencies (NHIS, FMOH, NPHCDA etc.).

Healthcare Management Review Volume 13

PAGE

040

Recommended early Steps by states Ÿ Develop and ensure passage of legal framework Ÿ Establish State Health Insurance Agencies Ÿ Recruit/deploy initial Management of Agency based on a lean administrative structure Ÿ Develop other operational documents such as operational guidelines, beneﬁt package

etc. Ÿ Deﬁne and prioritize coverage populations and programmes to adopt. Ÿ Start coverage as determined by funds availability

Role of NHIS Ÿ Provide matching funds for the poor and vulnerable through their equity funds/plans Ÿ Support Capacity building for SSHIS Ÿ Study tour for legislators and technical ofﬁcials Ÿ Workshops Ÿ Sharing best practices Ÿ ICT Infrastructure support and deployment Ÿ Coordination for States’ Schemes Ÿ Guide states in the development of legal frameworks

Healthcare Management Review Volume 13

PAGE

041

The Unvarnished

Truth

any execu ve believe that if they come up with the right strategy or business plan, their programme teams will “get it done” and execute the strategy as directed. O en it has been observed that if you do everything by the book of conven onal implementa on management you may s ll fail. Most problems are not technical but managerial. When technical errors cause programmes to fail, it is usually management that failed to put the right system in place. So those errors would be detected in me. Such problems stem from the framework and the mind-set that drive the tradi onal approach to programme implementa on, rather than from lack of process or prac ce. The level of ﬁt between the required and actual management style o en provides explana on for programme troubles and failures. As leaders in a coordinated revolu on, we must execute the reforms that make quality healthcare aﬀordable and accessible.

Implementation Management Healthcare Management Review Volume 13

PAGE

044

State Supported Health Insurance Scheme

â&#x20AC;&#x153;

Most healthcare executives fail to appreciate upfront the extent of uncer tainty and complexity involved in healthcare programmes (or failed to communicate the extent to each other) and failed to adapt their management style to the situation.

â&#x20AC;?

Healthcare Management Review Volume 13

PAGE

045

From Traditional to Adaptive Implementation Approach

he standard formal approach to implementation is based on predictable, ﬁxed, relatively simple and certain model. It is decoupled from changes in the environment or in business needs; once you have created the plan, it sets out the objectives and must be implemented as planned. “Managementas-planned” philosophy. Af ter the p ro g r a m m e l a u n c h , p ro g re s s a n d performance are assessed against the plan, and changes to the plan should be rare and if possible, avoided. However, most modern programmes are uncertain, complex and changing, and they are strongly affected by the dynamics of the environment, technology, or markets. Virtually most healthcare programmes undergo unpredictable changes and not completed exactly as planned. They differ from one another and “one-size does not ﬁt all.” To succeed you must adjust your plan to the environment, the task and the goal, rather than stick to one set of rules. In most healthcare programmes you can no longer assume that your initial plan will hold throughout the programme. Changes will take place and plans will have to be adjusted to the change. Sometimes you cannot even

build a complete plan for the entire effort. Instead you must establish a small pilot programme to create small-scale prototypes and include interim milestones to resolve important unknowns before you can commit to the full programme, or you must separate an unpredictable component from the next of your programme and treat it completely different from the bigger, more reliable task. The Adaptive Implementation Approach According to the adaptive approach, healthcare programmes are not just a collection of activities that need to be completed on time. Instead, they are business related processes that must deliver business results. Most programmes are not predictable or certain. Rather, they involve a great deal of uncertainty and complexity, and they must be managed in a ﬂexible and adaptive way. Planning is not rigid, ﬁxed, or shaped once and for all; instead it is adjustable and changing, and as the programme moves forward, replanning is often appropriate or even unavoidable. And the implementation management style must adapt to the strategic programme and its requirement. Although this approach represent a shift in thinking, it is inevitable if you want to meet today's implementation challenges. Healthcare Management Review Volume 13

PAGE

046

According to the adaptive approach, healthcare programmes are not just a collection of activities that need to be completed on time. Instead, they are business related processes that must deliver business results.

Pilot Before You Pile It is often better to overspend up front on piloting with quick, small implementations to save later resources and avoid mistakes and misunderstanding. A common way to deal with programme uncertainties is to build fast and sometimes small-scale prototypes. A prototype is an initial version of the programme, typically having reduced features and performance. The goal of making a prototype is to test your preliminary assumptions and obtain information that will help later when you define and build your final full scale programme. Prototypes let us do things quickly and test them as you go, rather than spend months writing requirements and specifications (which will change anyway), you can use prototypes to identify and fix bugs early rather than carry the problem to the full-scale products, where getting rid of them is difficult. In State Supported Health Insurance Programmes, you can pilot with the maternal and child health programme or the formal sector.

You may also need to try a pilot programme before making a commitment to the main effort. A small-scale pilot can be seen as a 'whole project prototype' and it serves the same objectives. A pilot programme let you deﬁne the fullscale programme in terms of objectives, requirements and your ability to make a more accurate estimate of the resources and the time needed for the full programme. “Uncertainty affects the number of iterations required during implementation and the number of prototype needed before requirements and designs can be frozen.” Uncertainty Risk

= =

Unknown What can go wrong

… clearly a great deal of programme risk depend on uncertainty but there are other factors which include complexity, time pressure, shortage of resources and inadequate skills.

Healthcare Management Review Volume 13

PAGE

047

The Adaptive Diamond Approach to Implementation Management

â&#x20AC;&#x153;

The adaptive approach to implementation diďŹ&#x20AC;ers from conventional model in its basic assumption. Instead of seeing a programme as a linear, predictable process of sequential steps, that can be determined with high level of certainty at initiation, the adaptive approach presume a programme as an unpredictable, non linear and iterative process. Many things are still unknown during the programme launch, initial assumptions are highly uncertain and many early decisions will most likely change as the programme progress.

â&#x20AC;?

Healthcare Management Review Volume 13

PAGE

048

Technology

Novelty

Complexity

Pace The Diamond-shaped framework help managers to distinguish programmes according to four dimensions: Novelty, Technology, Complexity and Pace (NTCP). The diamond analysis is helpful in assessing a programme mid course, identifying possible gaps in a troubled programme and selecting correcting actions to put the programme back on track. It provides a common language for discussion among executives, managers, teams and customers during the programme approval, contracting and monitoring process.

THE FOUR BASES OF DIAMOND: Technology: This base represents the programme's level of technological uncertainty. It is determined by how much new technology is required. It includes: low tech, medium tech, high tech, and super-high tech.

Novelty: This base represents the uncertainty of the programme goals and the market. It measures how new the programme's product is to the customer (enrollee & provider). It includes three types: Derivatives, Platform, and breakthrough.

Complexity: This base measure the complexity of the product (health outcomes), the task and the programme organization. It includes three types: Assembly, Systems, and Array (on system of systems).

Pace: This base represents the urgency of the programme â&#x20AC;&#x201C; namely how much time there is to get started or complete the job. It includes four types: Regular, fast/competitive, time critical and blitz. Healthcare Management Review Volume 13

PAGE

049

PRE MORTEM PERFORMING A HEALTHCARE PROGRAMME PRE-MORTEM A pre mortem is the hypothetical opposite of a post mortem. A post mortem in a medical setting allows health professional and the family to learn what caused a patient's death. Everyone beneď&#x20AC; ts except, of course, the patient. A pre mortem in a business setting comes at the beginning of a programme rather than the end, so that the programme can be improved rather than autopsied.

Healthcare Management Review Volume 13

PAGE

050

ealthcare programme fail at a spectacular rate. One reason is that too many people are reluctant to speak up about their reservations during the all-important planning phase. By making it safe for dissenters who are knowledgeable about the undertaking and worried about its weakness to speak up, you can improve the programme chances of success. Research reveals that prospective hindsight imagining that an event has already occurred – increases the ability to correctly identify reasons for future outcomes by 30%. The use of prospective hindsight method in a programme is called pre-mortem; it helps programme teams identify risks at the outset. A pre mortem is the hypothetical opposite of a post mortem. A post mortem in a medical setting allows health professional and the family to learn what caused a patient's death. Everyone beneﬁts except, of course, the patient. A pre mortem in a business setting comes at the beginning of a programme rather than the end, so that the programme can be improved rather than autopsied. Unlike a typical critiquing session, in which project team members are asked what might go wrong, the pre-mortem operates on the assumption that the “patient” has died, and so ask what did go wrong. The team members task to generate plausible reasons for the programme's failure.

A typical pre mortem begins after the team has been briefed on the plan. The leader starts the exercise by informing everyone that the project has failed spectacularly. Over the next few minutes those in the room independently write down every reason they can think of for the failure – especially the kinds of things they ordinarily wouldn't mention as potential problems, for fear of being in-polite. Although many project teams engage in prelaunch risk analysis, the pre mortem's prospective hindsight approach offers beneﬁts that other methods don't. Indeed, the pre mortem doesn't just help teams to identify potential problems early on. It also reduces the kind of damn-the-torpedoes attitude often assumed by people who are over invested in a healthcare programme. Moreover, in describing weakness that no one else has mentioned, team member feel valued for their intelligence and experience, and others learn from them. The exercise also sensitizes the team to pick up early signs of trouble once the programme gets under way. In the end, a pre mortem may be the best way to circumvent any need for painful post mortem.

Adapted from Gary Klein The author of : Sources of Power: How people make decisions, The Power of Lati Intuition

Healthcare Management Review Volume 13

PAGE

051

The

Rolling Wave

Planning Concept State Supported Health Insurance Scheme

“

Imagine, for example, that you decide to do a small pilot programme to test some unknown ideas. Obviously, there is no need to plan everything is advance. Once you work this short-term plan, you will know what you need to do next. Thus the project can be subdivided into sequence of short-term stages until the ﬁnal programme is completed. The results achieved in each stage will help you better deﬁne and plan the next stage.

...a structured way of doing this is called the Rolling Wave of Planning.

”

Healthcare Management Review Volume 13

PAGE

052

lanning a Healthcare programme typically includes preparing several plans, such as Work Breakdown Structure (WBS), schedule, budget, risk management plan, and so on.

what managers envision up front.

The classic approach is based on the belief that programme teams should prepare detailed plans at initiation and then stick to the plan as much as possible. This is “management-as-planned” concept which focus on the famous triple constraint. This mind-set is represented by the old saying “plan your work, and work your plan.”

How many times have you seen a healthcare programme team work so hard during programme initiation to prepare a detailed scheduling plan that spans the entire period of programme implementation? Such plans include every detail as accurately as possible and schedule each activity with exact date for completion. Soon after the programme initiation, the plans become outdated – things don't turn out the way planners expected them to and to stay accurate, the plan must be updated.

But real healthcare programmes cannot always follow that belief. In the real world, you seldom ﬁnd a project that sticks to its initial plan. In particular, healthcare programmes are substantially different from

Real-world teams do not bother updating the plan on a monthly basis. Often such 'mega plans remain monuments to the teams initial hard work while things move on without them (you may often ﬁnd such initial plans Healthcare Management Review Volume 13

PAGE

053

Master Plan: entire project

Medium detail plans: 4 to 6 months

Detailed work plans: weeks Time

displayed on the walls to impress visitors who have no clue what is really going on). The Adaptive Diamond Framework views programmes as dynamic, unstable, and hardto-predict processes. It assumes that change will take place during execution – changes in the environment, the business, the markets, technologies and people. According to this approach, project plans must be adapted to changes that could not have been predicted at the onset. Thus, a programme plan is not a ﬁxed document that is prepared once for the entire programme. Rather, programme plans are dynamic, living entities that evolve as the programme progresses and change when new information is revealed.

follow a process more like “plan some of your work, work that plan, and then re-plan the next piece of you work, and so on.” Rather than prepare detailed plans at the onset, you should plan only for those things that you are highly certain will not change. The idea is to replace “management as planned” concept with management as planned and re-planned. You should see the “State Health Insurance Programme” as a continuous process of action and reﬂection followed by more action. With his approach, you may not need to create a full scale progamme plan at the outset. Instead a short-term, less detailed plan often is all you need to launch the programme.

The solution is simple “rather than plan your work, and work your plan”, you should Healthcare Management Review Volume 13

PAGE

054

The idea is to replace “management as planned” concept with management as planned and replanned. You should see the “State Health Insurance Programme” as a continuous process of action and reﬂection followed by more action.

The diagram shows the three levels of the rolling wave of project plans. The width of the shapes represents the amount of detail in the plans at each level and the length of their time horizon. The plan shown at the top of the diagram is the master plan – the highest-level plan. It spans the entire project life cycle and contains very little detail. It outlines only the major milestone, such as completion of major phases, important delivery dates, or the customer payments schedule. This plan allows top management to see the big picture.

change, and hopefully the project will end at the predicted time. But if things go wrong, you may need to update even the master plan. The second plan is the middle-level plan. Its time horizon is usually four to six months. It is more detailed than the master plan, and it includes “medium-level” events that happen between major milestones, such as testing prototypes, issuing major purchase orders, and so on. This plan is directed to middlelevel managers who oversee the project's effort together with other projects in the same department or business. A new version of this plan is built every few months to prepare for the next middle-level period of the project.

If things go well, the master plan will not

According to Laufer's deﬁnition, plans should “stand the test of time.” Because you cannot predict with great accuracy every detail of the work years in advance, you should plan only those things that you know will not change. And you should continuously gather information that will prepare you for the next step of planning. Alex Laufer Healthcare Management Review Volume 13

PAGE

055

Complexity of State Health Insurance Programme Imagine you managing a dispersed collection of systems that function together to achieve a common purpose, sometimes called a â&#x20AC;&#x153;system of systemsâ&#x20AC;?. The programme involves streamlining the operational process, control the process and offer on-line information. In this case coordination would be more critical and you need to employ formal tools, extensive documentation and sophisticated software. H e a l t h c a r e o rg a n i z a t i o n s n e e d t o b u i l d t h e i r implementation management skills according to the hierarchy of systems and train people to build a system view overtime.

The Success of a “State Supported Health Insurance Programme”

e should see a healthcare programme’s success as a multidimensional strategic concept. Every healthcare programme needs more than one dimension for assessing success, and those dimensions var y in importance and significance, depending on the programme. Measuring organizational effectiveness on different dimensions is not new. It has evolved in recent years at the corporate level, as organizations have realized that assessment based on traditional financial and accounting measures is not enough. Kaplan and Norton developed the corporate balanced score card concept to address these issues. It includes four major dimensions: financial, customer-related, internal and innovation and learning measures Other studies have suggested adding yet another dimension, for a total of five: financial, market related, process quality, people development, and preparing for the future. But how does this apply to state health insurance programme: clearly any healthcare programme should address more than one stakeholders group. But above all success measures must reflect the strategic intent of

the state healthcare system and its business objectives for three reasons. First, if the programme does not serve the state healthcare system, why do it at all? Second, it should encompass success at different times: what may seem well done in the short run may end later in disappointment, and short term setbacks may turn into long-term rewards. The state health insurance programme should therefore be observed with different time frames in mind. “Success measures should reflect the interest of various stake holders who will be affected by the programme outcomes (enrollee and providers). Based on research, a comprehensive assessment of state health insurance programme success in the short and long term can be defined by five basic groups of measures. Ÿ

Programme Efﬁciency

Impact on the customer (population)

Impact on the team (providers)

Business and direct success preparation for the future.

Healthcare Management Review Volume 13

PAGE

058

Importance

Preparation for Future Business and Direct Success

Efciency

Impact on Customer and Team

Time

Project Completion Relative importance of success dimensions: A matter of Time

The State Supported Health Insurance programme should be observed with different time frames in mind. “Success measures should reflect the interest of various stake holders who will be affected by the programme outcomes (enrollee and providers). The impact on customer represents the major stakeholders perception and it is critical to the assessment of the state Health Insurance Scheme. It should show clearly how the programme addressed the population need for quality, affordable and accessible healthcare service.

Planning for success also involves preparing for the possibility of failure. You therefore need to assess what can go wrong with the programme and include it in your plan along with the success criteria. The possibility of failure (or what can go wrong) will serve as a basis for the detailed risk plan.

As time goes by, it matters less and less whether the programme has met its resource constraints, and in most cases, after about a year, it is almost irrelevant. While the second and third dimensions – impact on the customer and team – become relevant after programme completion, the time to think about them (as well as all the other dimensions) is during the project itself, when you have the power to inﬂuence them.

Adaptive implementation management focus in resolving programme uncertainty and makes necessary as the project progresses: steering control. Accepting the reality is the most important lessons healthcare executives and managers of State Health Insurance Programme need to learn in their quest to deploy this programme. They have the responsibility to control the programme uncertainty throughout programme.

Note: the preparation for the future expresses the long term beneﬁts of the programme and is obvious only after years have passed.

Note however that uncertainty decrease during programme implementation.

Healthcare Management Review Volume 13

PAGE

059

a Hole at the bottom of the

Sea

Draw a Line between Strategy and Execution, and Your Business is Bound to Fail

t is almost like Cartesian mind/body dualism: we tend to consider strategy and execution to be two different things. The top management of an organization (the mind, or brain) formulates a strategy, which is then supposed to be executed by the organization (the body). The eventual organizational performances will rely on the quality of both. This means that you can have a great strategy, but with a poor execution, your organization won't perform that well. Strategy and execution are distinct from each other. Whereas top management is supposed to 'think' and formulate strategies, it is up to the 'low level workers' or 'front-line employees' to just do it. It is not up to them to question the strategy, or provide input to the top management. They are usually provided with a manual, or policy guidelines and have to follow these. A clear cut in the division of tasks.

In theory that is though, but what happens if we look at more practical situations? Do the front-line employees simply follow their manuals, and do they only do what is stated and formulated by the top management? And on a more practical note: are top management teams able to formulate strategies in such detail that they provide answers to every situation a front-line employee might face? No. Front-line employees are constantly faced with new situations and have to make choices on how to tackle them. Front-line employees should be considered part of the policy-making community. In the end, they shape the policies and strategies by executing them in a certain way. It is plainly simple: strategy implementation in the end comes down to the people who actually implement it. So, the clear cut in the division of tasks, between the top management and the frontline employees, between mind and body, Healthcare Management Review Volume 13

PAGE

060

...are top management teams able to formulate strategies in such detail that they provide answers to every situation a front-line employee might face?

between strategy and execution, isn't that clear. It is a false metaphor, oversimplifying reality, with serious negative consequences. Some front-line employees may internalize the idea of a distinction between strategy and execution, resulting in a mere focus on faithful execution, rather than on doing what is best for the customer. They become mechanically obedient and eventually disillusioned and disconnected. At the same time, the top management team may fail to recognize the difficulty of implementing their rather abstract strategies down the line. When the implementation succeeds, they take the credits for the great strategy they developed, but when it fails, they blame it on a flawed execution. This leaves the front-line employees entirely out of the game: they will never be the cause of success, only of failure. Again, they become disconnected and there is no motivation for them to share their strategic insights. An external consultancy firm will have to be brought in to gather this information and deliver it to the top management, resulting in even more disconnectedness. Martin initiates the idea of perceiving strategy and execution as a white water river with choices cascading from the top to the bottom. They are made at various points in the river, and affect other choices that will be

made further downstream. The ﬁrst choices will encompass the larger, long-term ones, and the ones downstream will be more detailed and pragmatic. This model motivates employees on all levels in the organization to take responsibility for their actions and recognize the choices to be made as a result of their actions. All the actions taken, will then be aligned. This choice-cascade model centers around the idea of the encouragement of feedback. Because of this, knowledge of front-line employees will be able to end up upstream, enabling the top management to improve their future decision-making. This way, the quality of the process will improve, and the engagement of front-line employees is increased. They are empowered to become and remain part of the process. This is however easier said than done, as often the 'empowerment' to share information, remains nothing more than an attempt of the top management to convince the front-line employees to share information, while maintaining the division between strategy and execution. A real step forward when it comes down to empowerment should be taken. True and open dialogues between top managers and front-line employees should be held for their actions to become aligned. Adapted from: Hester Mourik and is based on the article

The Execution Trap by Prof. Roger Martin,

Healthcare Management Review Volume 13

PAGE

061

UNIVERSAL HEALTH COVERAGE

Challenges & Opportunities

Ÿ How can current funding ﬂows

even in the face of constraints buy more health? Ÿ How do we increase efﬁciency

and buy more health?

Healthcare Management Review Volume 13

PAGE

062

Ÿ How can current ﬁnancing and

delivery arrangements be improved and made to work together to

Ÿ How do we reduce pooling

fragmentation? Ÿ What is the basic minimum package

of health service to citizens?

niversal healthcare coverage is presenting unprecedented challenges and opportunities for the Nigeria healthcare organizations. Success in this new world with emphasis on improving quality, and eﬃcient patient care will require the development of new healthcare business and service models, the creation of new partnership and alliances, and the development of new capabilities and approaches to organizing eﬀectively around this model.

Healthcare Management Review Volume 13

PAGE

063

The NHIS has identified 3 groups to be targeted in achieving UHC

Characteristics

Challenges & opportunities

Structured work environment

Formal

Salaried, so premiums are deducted from source Covered for a broad package – dental, preventive Good HMO penetration

Informal

Poor and Vulnerable

More aggressive marketing Expanded scope of services and flexibilities in payment plans

Legislative framework in place

Incentivize low utilization of service as seen in conventional insurance

Less structured work schedule

Pooling through unions

Non-salaried but likely to afford premiums

Cases show targeting will significantly increase coverage rates

Health package could vary depending on economic status

Continuous advocacy and enlightenment

Capturing these group requires creative thinking and advocacy

Require assistance to overcome health needs

Live on less than $2/day

Constrained fiscal environment for social insurance

Contribute significantly to poor health outcomes

Unlikely to afford any form of premium Typically have significant health needs

With a high poverty rate, 1/3 of the population cannot afford to pay premiums Economic Growth and Poverty Reduction Population Growth and Poverty

Despite rapid economic growth in the last decade, the country has not experienced an equivalent reduction in it’s level of poverty The country’s performance is at odds with the general trend in of poverty reduction in similar performing economies Due to annual increases in population figure, the absolute number of Nigerians living in poverty is increasing The number of Nigerians living in poverty was 58 million in 2012/2013 The are disparities in poverty levels across the regions with poverty increasing in the north and decreasing in the south

Disparities in Urban/Rural Poverty

43% of the population in the urban area is in the highest wealth quintile while just 5% of the rural population in in the highest wealth quintile2

Vulnerability to Poverty

Approximately 58% of the Nigerian population live under 140% of the poverty line (70% in rural compared to 30% in urban areas)

60m: Estimated

number of Nigerians living in extreme poverty1

Despite increases in small scale agriculture in the last decade – close to 6% there has been little progress in poverty reduction in rural areas

Source: 1 Nigeria Economic Report. The World Bank; 2 National Demographic Health Survey (NDHS), 2013

Healthcare Management Review Volume 13

PAGE

064

Poverty rates vary across States in Nigeria and have implications for achieving State-led Health Insurance Coverage

In a fiscally constrained environment, government should prioritize these three issues Expand the fiscal space

Determine optimal payment systems options

1. 2. 3. 4.

Define and cost a minimum package of care Channel additional funds from the Basic Health care fund to the underserved group Leverage states counterpart funding for maximum impact Pool domestic resources â&#x20AC;&#x201C; explore existing models for pooling private sector funds into social investments

1. Review and determine most appropriate payment system i.e. capitation vs fee-for-service vs DRGs 2. Improve technical efficiency by incentivizing providers through a result based financing approach

Reduce the effects of market failure

1. Address potential adverse selection issues by consolidating pooled risks schemes 2. Addressing information asymmetry through strengthening regulatory oversight.

Credit HEALTH STRATEGY AND

3 8

DELIVERY FOUNDATION

Healthcare Management Review Volume 13

PAGE

065

QUALITY

OF CARE

C O S T OF CARE

Healthcare Management Review Volume 13

PAGE

066

WHAT IS YOUR QUALITY-COST STRATEGY? The Cardinal Focus for

Healthcare Providers DELIVER A HIGH QUALITY CARE & REDUCE UNNECESSARY COST Healthcare Management Review Volume 13

PAGE

067

THE QUALITY-COST IMPERATIVE FOR NHIS PROVIDERS

uality improvement is evolving into a strategy for fiscal stability as well as a critical priority in itself. It is important that we manage the internal costs, much of which can be attributed to inefficiency and rework. Healthcare providers have to quickly absorb the tools and techniques that contribute to effectiveness in this realm. “Healthcare providers have to tackle quality, efficiency and cost management to improve outcomes, increase value to patients and remain financially sound.”

improvement transformation will not succeed in bring about quality improvement. In most hospitals the cultural conversion takes several years. At the heart of the change is the system wide adoption of the Toyota Production System manufacturing methodology and the core values of respect for people and continuous improvement on which that methodology is based.

“If you don't have the fundamental cultural underpinnings at the heart of what you are doing, then you won't transform the organization and achieve enduring change.”

The transition to a lean culture require, among other things, a fundamental shift from the traditional command and control healthcare leadership process to one of continuous improvement management in which senior management’s primary role is deﬁning the purpose for which the organization exist and clearly communicating the purpose to every staff member. Real change in patient care, quality and cost efﬁciency cannot take peace without the rudimentary alteration in mind-set. The change in mind-set comes naturally to nurses because they are trained in problem-solving.

Any provider who is not focused on building the cultural aspects of a continuous

A quality initiative based on lean can achieve 30% reduction in the cost of care 50%

The ability to create lasting improvement in patient care while reducing waste and managing costs requires nothing short of a cultural upheaval.

Healthcare Management Review Volume 13

PAGE

068

Any healthcare provider who is not focused on building the cultural aspects of a continuous improvement transformation will not succeed in bring about quality improvement.

reduction in occupational safety and health administration recordable injuries and fall and medication reconciliation rates of zero on its redesign of inpatient collaborative care. A step by step approach is important. A critical part of senior management responsibility is the careful selection of a manageable number of quality improvement performance indicators at a time. A 10 page d o c u m e n t ﬁ l l e d w i t h 1 0 0 d i ff e r e n t performances metric does nothing to engage staff. Narrowing goals down to three or four targets is much more likely to win commitments. For example: the performance indicator for a hospital may include medication errors, productivity, and implementation of staff idea in the frontline. Each business unit – clinic, in patient, surgery, has its own productivity metrics with an organizational wide goal of 10% productivity improvement year over year with each representing N10million in improving operating income. The Chief Executive and Service Line Managers have to get at where the value is

created for the customer – the patient – to deeply understand the business and the barriers to improving process. It is really about understanding resource utilization at the frontline level. How can you know what is going on in the ICU unless you go to the ICU and see all the barriers your staff are facing. You can also employ the concept of Kaizen, the Japanese word for improvement, in an effort to understand and improve care processes. In a lean culture Kaizen is a model that humanizes the workplace and empowers employees to drive quality by looking for solutions and identifying and eliminating waste as part of their daily routines. For caregivers and other employees, Kaizen should be woven into everyday work life. There should be a collaborative network of providers interested in learning from each other to change their organization. “To accelerate the learning curve of organization’s commitment to looking at healthcare business in a transformative fashion and moving from an antiquated to a new management process there must be Healthcare Management Review Volume 13

PAGE

069

“

Since most costs are generated by medical doctors, providers should expose them to the economics of patients care looking at information on costs, outcomes, complication rates, antibiotic usage, repeat laboratory investigations, device usage, length of stay, discharge plans etc. and invite them to critic the cost vs outcomes data.” Is doctor A ordering drugs at variance with his or her peers are doing? Is length of stay higher or lower on a clinician specific or diagnosis – specific basis? This will drive change because clinicians are trained in the scientific method, so they respond well to good data. If you show them that the implant they are using is three times more expensive but does not get better results, they will pay attention to that.

”

Healthcare Management Review Volume 13

PAGE

070

“

Cost efficiency and Quality should move in the same direction. This should replace the traditional inverse relationship between the two variables. Better care can be delivered at lower cost and higher quality actually can drive cost reduction.

”

“Process innovation and a major shift in thinking will enable providers to lower cost and improve outcomes” All these imperatives around quality, safety and cost must be owned by top management?

collaborative network. This will help providers leverage on each other's experience to improve quality of care and generate value for the patient by understanding current best practices and then spreading those best practices uniformingly across the organization. The provider group should spearhead a QUEST programme. (Quality, Efﬁciency, Safety, Transparency). They should come together out of the shared belief to improve quality, safety and cost with transparency. It should be aimed at reducing errors, mortality, and inefﬁciency and improving patient safety and satisfaction. The innovation methodology of the Toyota Production System – automation of the delivery system – should not be based on the old process; you will run the risk of automating a bad process. This should be done front-end – changes should be made using process innovation methodology. It will improve patient satisfaction around emergency room waiting times. Rova College Adapted from: Susan Brik.

Healthcare Management Review Volume 13

PAGE

071

The systemic approach to quality management for Healthcare Provider Association

he healthcare provider association should adopt a systemic approach to quality management that treats all members as part of a single cohesive

entity.

Providers have to link the organizational ďŹ nancial health to clinical outcomes. This will be possible by moving the mind-set from being a healthcare delivery organization to a clinical quality organization. This can be accomplished by using a strategic initiative programme to stimulate the change in thinking. When a problem arises at one hospital, the facility performs a root cause analysis and shares what it has learned with the rest of the members. The lesson leaned may have potential for application across the provider network in which case it will be used to drive continuous improvement. If root cause analyses do not have national application, they are not adopted nationwide. Still, the ability to share lessons is very important for learning in a provider network.

â&#x20AC;&#x153;

Simple solutions to complex problems lead to breakthroughs in industries from retailing to personal computers to printing. ...So let's try health care, too. Clayton M. Christensen Healthcare Management Review Volume 13

â&#x20AC;? PAGE

074

How do we make healthcare affordable?

he challenge that we face-making health care aﬀordable and conveniently accessible to most people-is not unique to health care. Almost every industry began with services and products that were so

complicated and expensive to provide and consume that only people with a lot of skill and a lot of money could participate. The transformational force that has brought affordability and accessibility to other industries is disruptive innovation. Today's health-care industry screams for disruption. Politicians are consumed with how we can afford health care. But disruption solves the more fundamental question: How do we make health care affordable? Healthcare Management Review Volume 13

PAGE

075

he patient is weak, the situation is serious, but a cure is on the horizon—if we think differently about the underlying problem. Specifically, we need to innovate in health care just the way it is done in any other industry, by tackling the simplest problems first and by devising rules-based solutions to make care accessible and affordable.

requires deep training, intuition, and iteration to resolve into a problem that can be addressed in a predictable, rules-based way. Diagnostic abilities are the technological enablers of disruption in health care. Precise deﬁnition of the problem, in this and in every industry, is a prerequisite to the development of a predictably effective solution.

There are three lessons of industry disruption that can help cure this ailing industry.

In the past, business model innovation was common in healthcare. When the technological enablers for the diagnosis and treatment of infectious diseases emerged, most patient care was transferred away from hospitals to doctors' ofﬁces, and away from the doctors to the nurses. However, business model innovation has stalled in the last three decades. Regulations and reimbursement systems currently trap in high-cost venues much care that could be provided in lowercost, more convenient business models. Other disruptions fail because they lack new value networks that combine business models into coherent ecosystems that allow them to disrupt their predecessors.

Most disruptions have three enablers: a simplifying technology, a business model innovation, and a disruptive value network. The technological enabler transforms a technological problem from something that

Three key lessons from the history of disruptive innovation are particularly important for the disruption of health care. The ﬁrst is that while the technological enablers almost always emerge from the

The most essential innovations begin with simplicity and accessibility. Toyota made a name for itself in the United States ﬁrst with a Corona; the far more ambitious Lexus came later. Many other industries have been disrupted in a similar way, “There is little dispute that we need a system that is competitive, responsive, and consumer-driven, with clear metrics of value per naira spent.”

Healthcare Management Review Volume 13

PAGE

076

laboratories of leading institutions in the industry, the business model innovations do not. Almost always these are forged by new entrants to the industry. Regulators must beware, therefore, of attempts by the leading institutions to outlaw business model innovation. Regulation should facilitate it. What is in the interest of society most often does not coincide with the self-perceived interests of the leading institutions. The second key lesson is that disruption rarely happens piecemeal, where stand-alone disruptions are plugged into the existing value network of an industry. Rather, entirely new value networks arise, disrupting the old. Hence, disruptive business models such as value-adding process clinics, retail clinics, and facilitated networks must be married with disruptive innovations in insurance and reimbursement in order to reap the full impact in cost and accessibility. At the outset, knitting all these pieces together will require a much higher degree of integration than has been the norm in the health-care industry. Difﬁcult though it will be, these providers need to disrupt themselves. Employers will need to play a more proactive role in orchestrating the emergence of this new value network, compared to the reactive

posture they have taken in the past. Finally, we have seen a pervasive pattern in every industry that has been transformed through disruption. This same pattern characterizes what has happened to date with disruptive initiatives in health care. The energies, talent, and resources of the leading organizations in an established system always are absorbed in improving their best products, which are sold to address the most demanding applications in the industry. Why? Because the high end of most markets is where the most attractive profits are made, serving the most profitable customers. When a disruptive technological enabler emerges, the leaders in the industry disparage and discourage it because, with its orientation toward simplicity and accessibility, the disruption just isn't capable of solving the complicated problems that define the world in which the leading experts work. Always, the technological enablers of disruption are successfully deployed against the industry's simplest problems first. They then build commercial and technological momentum upon that foothold and improve, progressively displacing the old, high-cost approach application by application, customer by customer, disease by disease. Healthcare Management Review Volume 13

PAGE

077

Toyota's launch vehicle was a Corona, not a Lexus. Health care is no different. An illustration: Angioplasty has transformed the interventional care of coronary artery disease—making it much more affordable and much more convenient for many more people to receive effective treatment. It was initially deployed against partially occluded, easy-to-access coronary arteries. Luckily, angioplasty wasn't blocked from the market just because it couldn't beat the gold standard of open-heart bypass surgery, which was unquestionably the best way to resolve intractable blockages in complicated locations. But step by step, stent by stent, the minimally invasive approach has improved to the point where fewer and fewer people need bypass surgery. Now, pharmaceuticals, including lipid-lowering agents such as Lipitor, are disrupting angioplasty in the same manner. They were not withheld from the market because they couldn't dissolve deﬁant arterial blockages. But deployed as prevention, patient by patient, these "statins" demonstrate reabsorption of atherosclerotic plaques that can obviate the need for angioplasty. Doctors and hospitals, regulators, and policymakers need to convert to this religion because it isn't myth: it is true. The fact that

cost-lowering, accessibility—enhancing disruptive enablers can address only the simplest of problems at the outset is indeed a gospel of good news. It frees physicians and hospitals to focus their energies on what they do best-tackling complex medical problems and moving more and more problems along the spectrum from intuitive toward precision medicine. However, in the history of health care, industry leaders have repeatedly lobbied for legislation and regulation that block disruptive approaches from being used anywhere until they are certiﬁably good enough to used everywhere. This traps the industry where it began, in the expertiseintensive world of high costs. Generally, the leading practitioners of the old order become the victims of disruption, not the initiators of it. But properly educated, the leaders of the existing systems can take the lead in disrupting themselves—because while leaders instinctively view disruption as a threat, it always proves to be an extraordinary growth opportunity. We hope this map inspires some of you to step to the front and become leaders in a coordinated revolution, because the reforms that make health care affordable and accessible are indeed possible. Adapted from:

Clayton M. Christensen, Jerome H. Grossman, M.D. M.D. & Jason Hwang

TOYOTA'S LAUNCH VEHICLE WAS A CORONA, NOT A LEXUS. Always, the technological enablers of disruption are successfully deployed against the industry's simplest problems ﬁrst. They then build commercial and technological momentum upon that foothold and improve, progressively displacing the old, high-cost approach application by application, customer by customer, disease by disease. Healthcare Management Review Volume 13

PAGE

078

RECALIBRATING Nigeria Healthcare Delivery for the

INTERVIEW Extracts of HMR interview with Dr. Leke Petan on â&#x20AC;&#x2DC;Recalibrating the Nigeria Healthcare Delivery System for the Future

Dr. Leke Petan

Healthcare Management Review Volume 13

PAGE

080

What type of healthcare delivery model will you advocate for the future and why? Government should institute universal health coverage that thrives on universal healthcare insurance , where the public and private sector would be treated as one and scarce human and infrastructural needs would be maximized

particularly at the

primary healthcare level. Primary health centres should be accredited and brought into the NHIS scheme (unlike the present situation where they are not under NHIS scheme). More Private sector GP'S would also be brought in onboard while government takes over premium payment for the

vulnerable and more

particularly for children and women of child bearing age who should be guaranteed free assisted delivery(e.g Caesarian Section). This model of healthcare delivery will motivate our Diasporas healthcare community to come back and get involved at the secondary and tertiary levels where their skills and expertise are needed the most.

Healthcare Management Review Volume 13

PAGE

081

Why? This will broaden the health management system by maximizing human and infrastructural resources available in order to improve access to primary healthcare to all. The Federal government guaranteeing premium payment for the vulnerable especially women (to include assisted deliveries) and children will crash down the neonatal and maternal mortality rates. Encouraging those in the Diaspora and other similar skilled professionals and healthcare investors to come back with their specialist skills will in turn help to reverse the negative medical tourism scenario in the country thereby saving scarce forex and enhancing local capacity building and cheaper costs. What new recalibrations are required for the future? The new recalibrations are to lower the accreditation criteria for the NHIS health care providers at the primary health care level in order to allow the primary health centres to come onboard.

adequately and actuarially cover the premium for this new primary care package. What will be the trade oďŹ&#x20AC;s? The trade off's are also fairly straightforward and include(but not limited to) a policy in which no facility will be allowed multiple accreditation. For instance those accredited for primary care will not be accredited for secondary or tertiary level care and vice-versa. The reason for this necessary trade off is to ensure that the primary healthcare level base is widened ,adequately funded, appropriately and fully utilized through concentration of capitation payments which are automatic. This will in turn strengthen the primary healthcare system as well as the overall quality of health service delivery in this universal coverage concept we are proposing. Furthermore, it will reduce the undue congestion presently occurring at the secondary and worse still at the tertiary levels thereby allowing them to focus on cases that badly need their scarce specialist expertise as well as research activities that will in turn improve Heath outcomes.

To redesign the primary healthcare package into basic services the PHCs can effectively offer and at the same time recalibrate capitation payments to what will Healthcare Management Review Volume 13

PAGE

082

LEAPFROGGING Health Systems in Emerging Economies Credit World Economic Forum

Healthcare Management Review Volume 13

PAGE

084

Leapfrogging means using a new technology, operating model or pattern of behaviour to accelerate the development of a system. ...it has been used more broadly to describe a mindset, an ability to see and grasp opportunities. Healthcare Management Review Volume 13

PAGE

085

Trailing behind can be turned into an advantage. Trailing behind has advantages. Emerging economies are generally less burdened by the legacies of the past and enjoy a greater degree of freedom to design eďŹ&#x192;cient and cost-eďŹ&#x20AC;ective systems.

Healthcare Management Review Volume 13

PAGE

086

he term “leapfrogging” is over-used and often ill-defined. The concept first emerged in the 1960s in the field of industrial engineering. More recently, it has been used more broadly to describe a mindset, an ability to see and grasp opportunities. Leapfrogging means using a new technology, operating model or pattern of behaviour to accelerate the development of a system (be it an organization, industry or an entire economy) by helping it skip over development stages that had previously been unavoidable. In developed economies, techniques and structures that had been created to meet previous developmental challenges have tended to remain embedded in health systems, even after circumstances have changed or superior methods have become available. Outmoded organizational, behavioural and financial models can be e x p e n s i v e a n d d i ffi c u l t t o r e p l a c e . Leapfrogging helps to avoid such traps. A now-classic example is the introduction of mobile phones to remote areas of Africa. Those areas received the social and economic benefits of telephone networks without the sunk costs of massive landline infrastructure. They thus “leapfrogged” an entire stage of development, going directly from little or no telephone service to the same, efficient technology used in developed countries. For emerging economies, the most valuable use of leapfrogging is not just to catch up with developed economies – but to use

innovation that allows them to take a shortcut in reaching a more advanced development stage without accumulating inefficiencies along the way. Trailing behind can be turned into an advantage. Emerging economies can avoid the path-dependency problem of developed economies because they have fewer investments in physical infrastructure and weaker vested interests. They have the opportunity to assess the results and question the underlying assumptions of developed economies' health systems such as hospitalcentric systems and the necessity of highly trained physicians providing routine care. Accordingly, they can decide what they want to replicate or leap over. Leapfrogging can occur at two levels. At a macro level, leapfrogging means the transformation of an entire system, for instance via comprehensive infectious disease programmes. This kind of large-scale change is very challenging and rare. At a micro level, leapfrogging means discrete but significant changes within specific components of the health system, such as task shifting within the workforce, revamping vaccine supply chains or leveraging innovation in medical diagnostics. The two conceptions of leapfrogging can be mutually reinforcing. A series of small innovations can lead to a macro-level transformation. Conversely, macro-level change can guide micro-level change. For example, a comprehensive infectious disease programme will define the set-up of service delivery points and prevention campaigns .

Healthcare Management Review Volume 13

PAGE

087

Exhibit 5: The Life Course Approach Helps Identify Areas of Major Impact Source: WHO Europe, Health at key stages of life: The life-course approach, 2011, BCG

1 Life stages

2 Maternal and newborn health

Maternal & prenatal

Ideal state

Requirements

Actual state

Child and adolescent health

Adult and reproductive health

Infancy

- Increased nutritional intake - Skilled attendance at birth

Healthy ageing

Nonexha exam ustive ples - Breastfeeding - Vaccination

- Nutritious food - Trained midwifes

- Nutritious food - Availability of vaccines

- Malnutrition - Absence of trained midwifes

- Malnutrition - Absence of vaccines

Leapfrogging as a method to close the gap (quickly, cost-effectively and with scale) between actual and ideal state.

A valuable tool for conceptualizing an ideal health system is the “life course” concept developed by the World Health Organization (WHO) (Exhibit 5). Different stages of life require different resources, investments and intervention strategies. For example, the infrastructure, technology and workforce needs for maternal and child health interventions are largely different from those for ageing populations. An ideal health system must provide care for individuals at all stages of life.

Healthcare Management Review Volume 13

PAGE

088

Exhibit 4: Proposed Health Systems Vision Focuses on Better Health Outcomes, Higher Individual Satisfaction and Financial Sustainability

Sources: Expert interviews, Working Group discussions, literature survey, BCG

Achieve better physical and mental health outcomes across all demographic and socioeconomic groups

Improve individuals’ satisfaction with the health system by respecting their dignity

Keep the provision of health ﬁnancially sustainable for both individuals and the

The three objectives are interdependent. They can be mutually reinforcing (for example, streamlining referral systems improves patient experience and cuts costs) or they may require trade-offs (e.g. improving outcomes through new but costly procedures). The art of designing an ideal health system consists of balancing these objectives and making them work together in a virtuous circle. Many developed economies have ended up in a vicious cycle: health outcomes and individual satisfaction stagnate, while costs increase. Achieving a balance that maintains the dignity of individuals requires that the following three fundamental principles be observed: – Health is an individual right and responsibility and is crucial to human dignity. Health activities and interventions must be accessible and affordable for all individuals. Their dignity must be respected. – Health is an element of the common good. Health issues should be approached with socially optimal solutions in mind. All individuals beneﬁt from good public health. – Health demands a holistic perspective. Health should be a crucial part of economic and social development and should be embedded in all government policies in a coordinated manner. Healthcare Management Review Volume 13

PAGE

089

Acceleration

How?

What?

Scalability

Cost-effectiveness

While leapfrogging effects are usually the intended results of careful design, they can also be serendipitous. The case study on introducing antenatal ultrasound screening to rural Uganda illustrates this point: what started as a medical product innovation led to a number of unintended positive effects, empowering women to take a more active role in health choices surrounding their pregnancy. To be considered leapfrogging, a change must create a transformative impact satisfying three distinct criteria: 1) it must accelerate the health system's development (i.e. it must reduce the time needed to get results); 2) it must be costeffective (i.e. it must achieve the same or better results at the same or lower costs than traditional methods); and 3) it must be scalable (i.e. it must accommodate

expansion efďŹ ciently). Leapfrogging in health systems requires certain enabling conditions. These include a minimum level of physical infrastructure (e.g. basic sanitation and electricity supply) and a minimum level of workforce sophistication (e.g. reading or computer literacy). An environment or mindset that encourages and rewards leapfrogging is also necessary. Key aspects of such an environment are: a policy framework creating a favourable environment for innovation, both within and outside the health system; the agility to adapt to new trends and evolving patterns of medical needs; and ďŹ&#x201A;exibility in the design and implementation of health polices to suit different contexts and cultures.

Healthcare Management Review Volume 13

PAGE

090

Leapfrogging Matrix

TECHNOLOGY

OPERATING MODEL

BEHAVIOUR CHANGE

“Technology” encompasses new health-related activities and products. For emerging economies, the most powerful technological innovations are often those that are simpler, more affordable and more durable than existing solutions.

“Operating model” refers to any modiﬁcation in the organizational set-up and process design of healthrelated activities. This includes, for example, changes to the roles, workﬂow and incentives of health workers at a given service delivery point.

“Behaviour change” refers to the evolution of the preferences and conduct of individuals (e.g. patients or health workers) and organizations (e.g. payers) acting within the health system. It could include the adoption of different lifestyles by individuals or changes in the way physicians interpret their roles within the health system.

While innovations in the organizational and behavioural ﬁeld can happen by themselves, more often than not, they are innovations of a secondary order, triggered by new technology. By the same token, technological innovation usually has a greater impact and is longer-lasting if it translates into changes in operating model and behaviour.

Healthcare Management Review Volume 13

PAGE

091

Developing sustainable Health Systems

he opportunity for emerging economies to set their health systems on a path to sustainability is unprecedented. By 2022, an estimated one third of all global health expenditure will occur in emerging economies. For every additional US$ 100 spent on health in 2022 (compared with 2012), US$ 50 will come from emerging economies. Whether this increased investment will lead to the difﬁcult challenges that developed economies now face or to a transformation of emerging economy health systems depends on decisions being made today. Trailing behind has advantages. Emerging economies are generally less burdened by the legacies of the past and enjoy a greater degree of freedom to design efﬁcient and cost-effective systems. This allows them to leverage technological advances more easily and to learn from the experiences of developed economies. Seizing this unique opportunity requires an innovative, well-coordinated and implementable set of actions that relies on the expertise, support and collaboration of diverse stakeholders. Thus the initiative Leapfrogging in the Health Systems of Emerging Economies: Transformation Towards Sustainability sets out to identify

insights for emerging economies. The initiative will last three years and its objectives are twofold: to describe a health system vision based on key lessons from the experiences of developed and emerging economies and to develop potential paths for the health systems of emerging economies to leap over the problems encountered by developed economies as they achieve this health system vision. The initiative will yield a holistic understanding of health system challenges in emerging economies and create strategies to ensure systems are ﬁnancially sustainable, while also delivering high quality, cost-effective and accessible care that satisﬁes individuals' expectations. What makes this initiative different from similar ones is that it brings all relevant stakeholders together to work towards the vision in a new way: it puts preserving human dignity at the centre of all efforts. Unfortunately, in recent years, economies have focussed too much on health outcomes at the expense of the individual. This initiative seeks to help re-humanize health. To this end, a set of fundamental principles are proposed to guide the work on identifying leapfrogging opportunities. Emerging economies face a major and growing challenge to their ambitions to put their health Healthcare Management Review Volume 13

PAGE

092

First, the costs of developing their health systems in the same way as developed economies are prohibitive. Second, many emerging economies face a double disease burden.

The Context and The Problem

Third, the drivers of demand and supply for health services in emerging economies are more complex and diverse than in developed economies.

systems on a path to sustainability. As they try to catch up with more advanced health systems, they often replicate the path of developed economies. In following those examples, however, emerging economies risk manoeuvring themselves into ďŹ nancially untenable situations which could be even worse than those developed economies face today. Three main factors exacerbate the challenges facing emerging economies. First, the costs of developing their health systems in the same way as developed economies are prohibitive. Nigeria, for example, currently has roughly 14% of the number of doctors per capita of OECD countries. To catch up, Nigeria would need approximately 12 times as many doctors by 2030, requiring, under current training models, about US$ 51 billion â&#x20AC;&#x201C; or 10 times current annual Nigerian public health spending (Exhibit 1). Second, many emerging economies face a double disease burden. On the one hand, they are struggling to satisfy demand for basic health services and to reduce the incidence of preventable communicable diseases. At the same time, they face escalating incidence of noncommunicable diseases driven by aging

populations and unhealthy lifestyles. Third, the drivers of demand and supply for health services in emerging economies are more complex and diverse than in developed economies. In Nigeria, for instance, poverty and poor basic health combine with violence and environmental factors to create strong demand for healthcare at the same time that weak infrastructure and delivery systems limit supply. Historically, emerging economies have underinvested in health: in 2012, their GDP allocation for health was, on average, 5.6%, less than half that of developed economies (12.5%). This has led to shortages in health infrastructure and workforce. Emerging economies need to make the right investments now if they want to avoid the problems of developed economies. The evolution of health systems is highly path-dependent: largescale investments in infrastructure and workforce determine the course of development for decades to come. Similarly, once established, individuals' expectations from health systems are difďŹ cult to change.

Healthcare Management Review Volume 13

PAGE

093

Emerging economies' share of global health expenditure is growing rapidly. Emerging economies account for 21% of global health expenditure, up from 10% in 1995. By 2022, one third of global health expenditure, roughly equal to developed economies' expenditure in 2005, will occur in emerging economies. For every additional US$ 100 spent on health in 2022 (compared with 2012), US$ 50 will have come from emerging economies. However, higher investment does not necessarily translate into better outcomes. South Korea, for example, spends only 25% per capita what the United States spends per capita, yet still achieves better outcomes (measured in health-adjusted life expectancy). In many emerging economies there is unprecedented interest in sustainable solutions. The momentum for change is coming from increasingly well-educated populations demanding greater access and higher quality care. National and international leaders and private sector actors recognize that equitable access to high-quality care contributes to political stability and economic growth. Policy-makers must choose one of two paths: the familiar, but long, expensive and unsustainable path of developed economies – or a shortcut that leads to a sustainable future. Emerging economies are well suited to the second path. They have fewer impediments to change than developed economies: fewer sunk costs of existing

infrastructure and equipment, lower fixed costs from building overcapacity, weaker vested interests (e.g. health professional associations) and a less divided public (e.g. privacy laws in developed economies that make data sharing and use difficult). They also have at their disposal disruptive technological innovations, alternative operating and financing models and new legal frameworks that were not previously evident or even possible for developed economies. Putting a health system on a path to sustainable development requires an understanding of the intended destination – the vision of an ideal health system. Health is generally a local matter. No universal model exists that will work for every country. It is appropriate for policymakers to approach the challenge of developing their own vision with due humility. Whatever its particular design or implementation, however, an ideal health system should pursue three fundamental objectives: –– Better outcomes: Achieve better physical and mental health outcomes across all demographic and socio-economic groups through timely and effective interventions. – Individual satisfaction: Improve individuals' satisfaction with the health system by respecting their dignity. – Financial sustainability: Keep the provision of healthcare affordable for both individuals and the economy as a whole.

Healthcare Management Review Volume 13

PAGE

094

Case Study: Organizational Innovation in Medical Service Delivery in India

h i l e We s t e r n h e a l t h c a r e providers struggle with ever increasing cost, some healthcare providers in India have managed to cut prices for care drastically without compromising quality. They now perform a large number of interventions, ranging from antenatal care to open-heart surgery, at as much as 95% below the prices charged at hospitals in the developed world. Their outcomes compare favourably with results in developed economies. Cost differentials between India and developed economies are only a minor factor explaining these lower prices. A more important factor is these providers' operational set-up, which challenges traditional ways of setting up points of care, harnessing resources and deﬁning workforce roles. This set-up is based on three organizational principles. First, care is delivered via a huband-spoke set-up. Providers strive to treat the majority of ailments at primary care facilities located within communities (spokes). A smaller number of specialized secondary and tertiary care facilities, which are signiﬁcantly more costly to operate, act as referral centres (hubs). LifeSpring Hospitals, a chain of maternal clinics, takes this organizational principle even further by avoiding investments in specialized care altogether. It

instead collaborates with paediatric hospitals as points of referral for the few mothers (2% to 3%) requiring intensive care. The second principle is maximization of asset utilization. The providers limit capital investment by concentrating expensive equipment in central hubs or sharing it between spokes, ensuring that it is being used extensively. For example, Narayana Health, a chain of cardiac hospitals, runs its operating theatres six days a week, from early morning to late night. LifeSpring Hospitals combines different clinics into geographic clusters that share expensive equipment. The third principle is maximization of workforce productivity: the providers strive to match the skill level of health workers with the difﬁculty of the task at hand, preventing staff from performing tasks for which they are overqualiﬁed (taskshifting). Fortis Healthcare, a multi-speciality hospital chain, for instance, concentrates critical care physicians at a centrally located intensive care command centre, from which they diagnose and monitor patients at remote ICUs via telemedicine. This ensures high utilization of costly specialists' skills, while improving the quality of treatment through enhanced collaboration between specialists.

These Indian healthcare providers have managed to leapfrog the costly mistakes of their counterparts in the developed world, such as the overemphasis on secondary and tertiary care and the ineffective use of expensive equipment. Many of these providers have seen impressive growth and plan to scale up extensively, including outside India. Some already have a strong presence across Asia, and are planning expansion of their business model to developed economies. While this model is highly scalable and transferable, it is not ideal for every context. One limit is that it requires a large enough volume of patients to make specialization proﬁtable. Healthcare Management Review Volume 13

PAGE

096

Healthcare Management Review Volume 13

PAGE

097

Pesinet: Deploys community health workers with limited expertise to detect and monitor childhood diseases with remote assistance from physicians. International Consortium for Health Outcomes Measurement : Deﬁnes global standards for measuring health outcomes and fostering better decision-making.

Clinical decision software used at MinuteClinic : Enables nurse practitioners to treat routine ailments with computerized medical guidelines on diagnosis, treatment and drugs. Kenya Integrated Mobile MNCH Information Platform : Provides pregnant women with mobile-phone-based health information to promote safe pregnancy.

Workforce

Hygeia Community Health Care (HCHC): Provides low-income populations in Nigeria with affordable health insurance covering essential treatment. National Committee on Public Health in France: Creates an inter-ministerial committee to act as a steering body in coordinating health policies across all ministries concerned.

RSBY Smart Card: Uses biometric smart cards to register low-income (and often illiterate) insurance takers, streamline administration and service delivery and facilitate data collection. Electronic Health Record System in Estonia: Creates a nationwide, integrated electronic health record system to improve the quality and efﬁciency of diagnosis and treatment.

Information

Financing

Leadership/ governance

Proven example

Nascent example

Sugar Tax in Norway : Charges excise tax on foods with high sugar content to discourage unhealthy consumption habits.

Discovery Insurance : Rewards health insurance buyers for healthy lifestyles through a variety of beneﬁts.

"Trafﬁc light" nutrition labelling in the United Kingdom : Simpliﬁes food labels to avoid obesity by helping consumers better understand products' health impact.

Narayana Health’s cost awareness policy: Incentivizes physicians to take ﬁnancially prudent decisions and make suggestions for cost savings and process improvements.

CARE hospitals : Improve equipment longevity and reduce waste by safely reusing devices sold as single-use products.

Medical products

1 USAID "Deliver" Project : Provides technical assistance to streamline medical supply chains in emerging economies, increasing availability and affordability of medical products.

Pr o j e c t Masiluleke

Philips Healthcare Infant Warmer : Provides reliable, easy-to-use and cost-effective infant thermo-regulation to reduce neonatal mortality in low-income countries.

Prevention & health promotion

Abdul Latif Jameel Poverty Action Lab study on immunization in India : Provides non-monetary incentives for parents to immunize their children, thereby overcoming cognitive biases.

Behaviour change

Fortis & GE Healthcare tele-ICU : Reorganizes delivery of critical care by connecting remote ICUs with centrally located intensivists through telemedicine.

Proteus Helium system : Administers hypertension therapy remotely via smart phone technology, moving care from service points to homes.

Operating model change

Service delivery

Greenstar: Conducts social marketing to raise public awareness of reproductive health, leveraging private healthcare providers to act as franchisees.

Technology Singapore Health Promotion Board : Invests in the maintenance of public health using a holistic approach, bringing health considerations into every aspect of people's daily lives.

A Project Masiluleke : Leverages mobile technology for HIV/AIDS andTB prevention through phone-based counselling and text-messagesupported self-testing.

Health system categories

Innovation types

Sources: Expert interviews, project partner organizations, desk research, BCG

Exhibit 9: Leapfrogging Matrix with Concrete Examples

Case Study:

Providing Access to Antenatal Ultrasound Care to Rural Communities in Uganda

he United Nation's Millennium Development Goal 5 has made the reduction of maternal mortality a priority. In Uganda, women still face a 1 in 49 lifetime risk of dying during childbirth, compared with a 1 in 9,200 risk in OECD countries. Reducing maternal mortality requires a concerted effort among public, private and non-proﬁt stakeholders. Philips Healthcare's partnership with the NGO “Imaging the World” to improve antenatal care in Uganda is an example of this type of collaboration. The initiative involves all three types of health system innovation – technology, operating model change and behaviour change. The project provides specially designed ultrasound screening units to rural communities in Uganda. The units are easy

to use, highly reliable and provide diagnostic accuracy at low cost. Comparable ultrasound screening units tailored to emerging market needs have recently also been presented by GE Healthcare and a number of research institutes around the world. In addition to low-cost screening devices, the project also offers a training programme on antenatal ultrasound examination to build local expertise and relies on a simpliﬁed screening protocol based solely on surface anatomic landmarks. The protocol can be learned by nurses at rural health centres in only three days. Ultrasound images are transmitted wirelessly to centrally located experts for remote diagnosis, which makes it possible to tap into scarce expertise (there are only 34 trained radiologists in Uganda).

Healthcare Management Review Volume 13

PAGE

098

Fathers attended ultrasound exams to view their child on screen, sparking their interest in maternal health.

A small fee (less than US$ 2) per ultrasound exam allows clinics to break even after about three years. All patients in rural Uganda were able to aďŹ&#x20AC;ord this fee. The programme is substantially more costeďŹ&#x20AC;ective than similar procedures in developed economies

The initial results of a pilot conducted in Uganda are encouraging. Sixteen percent of women screened needed and received a change in care management (follow-up screenings, dietary change, skilled birth attendance or referral to secondary care). There was also an increase in the number of women seeking skilled birth attendance among those not expecting complications. There were also positive spillover effects beyond those intended. The ďŹ rst was a more active role for fathers, the primary health decision-makers in Ugandan families, in the health choices surrounding pregnancy: fathers attended ultrasound exams to view their child on screen, sparking their interest in maternal health. Second, there was also an overall improvement in community health thanks to the use of ultrasound exams for

community outreach, i.e. as an avenue for general health education (e.g. HIV and other infectious diseases) and prevention (e.g. malaria and hookworm). A small fee (less than US$ 2) per ultrasound exam allows clinics to break even after about three years. All patients in rural Uganda were able to afford this fee. The programme is substantially more cost-effective than similar procedures in developed economies. This provides an opportunity for emerging economies to leap over the pitfall of large investments in a specialized workforce and expensive but underutilized equipment. Positive results from this pilot project support a planned scale-up in Uganda and in other sub-Saharan countries.

Healthcare Management Review Volume 13

PAGE

099

Case Study:

Reducing Maternal and Newborn Mortality through Simple and Inexpensive Product Innovation Emerging economies are breeding innovation across all parts of the health system. Successful leapfrogging practices from emerging economies can change the direction of key learnings and help developed economies improve their own health systems (“reverse innovation”).

very year, 260,000 women die from causes related to pregnancy and childbirth, 99% of them in emerging countries. Eight percent (20,000 women) die as a result of obstructed labour. Achieving falling maternal mortality rates – and improved health outcomes in general – in a financially sustainable manner in emerging economies requires new technologies that can do more for less. These technologies must fit an environment characterized by limited financial resources, a shortage of skilled health workers and limited availability of medical infrastructure. This environment requires simple, easy-touse products that maximize patient satisfaction while minimizing resource utilization. An example is the “Odon device,” a new obstetrical instrument for assisted vaginal delivery in case of complications during the second stage of labour (obstructed labour). The device is a simple, inflatable plastic sleeve slipped around the baby's head to gently pull the newborn through the birth

channel. It is meant to be a safe, simple and cost-effective alternative to traditional procedures like forceps or vacuum extraction as well as some Caesarean sections. Clinical trials are currently under way. The Odon device could significantly reduce fatal maternal and newborn complications at an estimated cost of US$ 50 per device or potentially even less. The Odon device is the result of a partnership between WHO and medical technology company Becton Dickinson. This cooperation began at the World Economic Forum Annual Meeting 2012 in DavosKlosters. The Odon device shows how acceleration of health system development towards greater value-consciousness, an important design principle for any financially sustainable health system, demands innovative solutions that improve health outcomes while keeping costs down. A more advanced development stage without accumulating inefficiencies along the way.

Healthcare Management Review Volume 13

PAGE

100

The Odon device shows acceleration of health system development towards greater value-consciousness demands innovative solutions that improve health outcomes while keeping costs down.

Trailing behind can be turned into an advantage. Emerging economies can avoid the path-dependency problem of developed economies because they have fewer investments in physical infrastructure and weaker vested interests. They have the opportunity to assess the results and question the underlying assumptions of developed economies' health systems such as hospital-centric systems and the necessity of highly trained physicians providing routine care. Accordingly, they can decide what they want to replicate or leap over. Healthcare Management Review Volume 13

PAGE

101

DR. IBRAHIM KANA MBBS, FMCOphth, PGDPA, Cert. Health Financing/PBF

Na onal Programme Manager

“

We need a method of delivery that ensures we get more health for the money….

”

Healthcare Management Review Volume 13

PAGE

102

Saving One Million Lives Program for Results (SOML PforR)

...a paradigm shift from inputs to emphasis on results

“

The Program which seeks to catalyze change in the way health business is done by focusing on results and governance will be ﬁnanced by a $500million International Development Association (IDA) credit to the Federal Republic of Nigeria over a period of 4 years. The resources are then disbursed to the states based on performance.

”

Healthcare Management Review Volume 13

PAGE

103

he Program for Results (PforR) is a performance based program of the Federal Government of Nigeria (FGON) assisted by the World Bank. It supports the Government's existing Saving One Million Lives (SOML) initiative by providing incentives based on achievement of results (health outcomes) and helping to drive institutional processes needed to achieve them.

he SOML Initiative was launched by the President of Nigeria in October 2012 in response to the poor health outcomes in the country, particularly for mothers and children. It is estimated that almost 1 million women and children die yearly, largely from preventable causes. SOML represents a bold attempt to improve maternal and child health outcomes so that they are more in keeping with the country's level of wealth; and focuses on six important aspects (“pillars”) of maternal newborn and child health (MNCH) that can save lives. The pillars are: (1) Improving Maternal, Newborn and Child Health; (2) Improving routine immunization coverage and achieving polio eradication; (3) Elimination of Mother to Child Transmission of HIV; (4) Scaling up access to essential medicines and commodities; (5) Malaria control; (6) Improving child nutrition.

The FGON's program document for SOML plainly states that “Continuing business as usual is not a viable option.” It goes on to stress that SOML represents “a shift in focus from inputs to focusing on results and outcomes.” The

The Program-for-Results (PforR) is not a typical World Bank project which focuses on inputs and activities for procurement using World Bank rules and procedures. Rather, it uses country systems and processes, giving health managers substantial autonomy in managing and producing health results. The Program which seeks to catalyze change in the way health business is done by focusing on

SOML program is also predicated on the fact that “bold innovations and changes in the approach to delivery in the sector are necessary.” The SOML program involves: (i) re-orienting the discussion of service delivery to results rather than just inputs; (ii) clearly articulating strategic priorities for the FGON and the rest of the health sector and strengthening the long term commitment to improving the delivery of these high impact interventions. It does not say that other interventions are unimportant, just that the selected intervention (“pillars”) are priorities that should get the ﬁrst call on r es o u r ces , eff o r t, an d atten tio n ; ( iii) establishing a limited set of clear and measurable indicators by which to track success; (iv) strengthening data collection so that these indicators can be measured more frequently and more robustly; (v) bolstering accountability so that managers and health workers at all levels are engaged, encouraged, and incentivized to achieve better results; and (vi) fostering innovations that increase the focus on results and include greater openness to working with the private sector. Healthcare Management Review Volume 13

PAGE

104

results and governance will be ﬁnanced by a $500million International Development Association (IDA) credit to the Federal Republic of Nigeria over a period of 4 years. The resources are then disbursed to the states based on performance. States are the greatest beneﬁciaries of the program, receiving up to 82% of the total credit sum as incentive for improved performance

under the various disbursement linked indicators (DLIs). States get rewarded for improvements in performance from their own baseline. States in each geopolitical zone are also ranked according to their performance and the best performing state, 'zonal champion' receives an additional bonus. Similarly, the best performing state in the countr y 'national champion' receives a performance bonus.

The SOML Program for Results To help implement SOML, the FGON requested World Bank support through a PforR operation. The SOML PforR rewards federal and state governments based on their performance in increasing utilization of maternal and child health interventions. The Program Development Objective is to “increase the utilization and quality of high impact reproductive, child health and nutrition interventions.” Under the SOML PforR, states will be rewarded for their performance based on objective indicators using data from household and health facility surveys as well as achievement of certain process indicators related to implementation of a performance management system; and consolidation of primary health care (PHC) management and resources under one institution. The Federal Government will also be rewarded for their performance related to conduct of household and health facility surveys and publication of the results in newspapers; technical assistance for a performance management system that builds capacity at state level; establishment of an innovation fund; and publication of a consolidated budget execution report covering all income and expenditures for PHC.

Healthcare Management Review Volume 13

PAGE

105

Immuniza on

Neonatal and child health

Nutri on

E-MTCT

Maternal Health

Malaria Control

Save one million lives and more while improving overall health system performance

Logis cs and Suppy Chain Innova on and Technology (ICT & Private Sector Engagement)

SOML PforR at a

Glance

Ÿ P4R - an approach to structuring the ﬂow of resources to pay for results—desired goals,

outcomes, and impacts—rather than simply paying for processes or reimbursing activity costs (inputs) Ÿ Federal Government’s ﬂagship intervention to improve Maternal and Child Health by

changing Federal-State relationship to become a results-based partnership. Ÿ Designed to support FGON’s SOML program aimed at inﬂuencing the states through:

collection of robust data on service delivery at community and health facility level and feeding it back to states; rewarding states for better performance; provision of technical assistance

Healthcare Management Review Volume 13

PAGE

106

Ÿ Aimed at delivering high impact, evidence based, cost effective

health interventions based on 6 “pillars”…… and 2 “Enablers” Ÿ The objective is to achieve wider coverage of these interventions

that currently suffer from poor access and utilization.

Ÿ Not a new program but focus on strengthening our Health System to improve on existing

Maternal and Child Health initiatives by government and non-state actors. Ÿ

A focus on paying for results (outputs) rather than ﬁnancing inputs.

Ÿ States are the greatest beneﬁciaries of the program, receiving up to 82% of the total credit

sum as incentive for improved performance under the various Disbursement Linked Indicators (DLIs). Ÿ NOT a project, WB not directly involved in procurement or ﬁnancial management – uses

country systems (GIFMIS, Public Procurement Act etc) Ÿ Agree on results but give managers substantial ﬂexibility in how they achieve those results Ÿ Involves Independent and rigorous measurement

Healthcare Management Review Volume 13

PAGE

107

DLI 1 - Quantity of Services

SOML PforR Allocation of $500M by Disbursement Linked Indicator

DLI 2 Quality of Care 16%

DLI 3 Date Collection & Utilization

11% 61%

DLI 4 - Private Sector Innovation DLI 5 - Transparency in PHC

Disbursement Linked Indicators (DLIs) The PforR will provide funds to the federal and state governments based on a set of ďŹ ve DLIs. I.

DLI 1- Increasing Utilization of High Impact Reproductive and Child Health and Nutrition Interventions

ii.

DLI 2- Increasing Quality of High Impact Reproductive and Child Health and Nutrition Interventions.

iii.

DLI 3- Improving M&E Systems and Data Utilization

iv.

DLI4 - Increasing Utilization and Quality of Reproductive and Child Health and Nutrition Interventions Through Private Sector Innovations

DLI5 - Increasing Transparency in Management and Budgeting for PHC

Healthcare Management Review Volume 13

PAGE

108

18% States are the greatest beneﬁciaries of the program, receiving up to 82% of the total credit sum as incentive for improved performance under the

States

various Disbursement Linked

Federal

Indicators (DLIs).

82%

SOML PforR and UHC Ÿ SOML PforR will increase the coverage of vaccines, nutritional

supplements, antenatal care and delivery attendance to everyone, regardless of status. Ÿ This allows the majority to access basic healthcare and reduces the

risk of serious morbidity and catastrophic spending while insurance markets continue to develop. Ÿ In this way SOML PforR contributes tremendously to Universal Health

Coverage (UHC).

Healthcare Management Review Volume 13

PAGE

109

Policy & Programme Linkages

Responsibilities of the

States

Ÿ Appointment of a “Lead” with commensurate capacity to be accountable for the performance

management process in each State/FCT; Ÿ Start preparing plans for the use of initial investment funds, focusing on:

Analysis of current PHC situation using all data How to improve supervision of PHC facilities Possible innovations to introduce on pilot basis Figure out how to quickly improve coverage of key interventions and quality of care (to earn funds under DLIs 1.2 and 2) Ÿ Initiate programs aimed at addressing the weaknesses which may include Social Health

Insurance, Conditional Cash Transfer and many other intervention mechanisms to be agreed upon with the PMU before fund disbursement; Ÿ Start discussions with private sector entities on opportunities for Public-Private Partnerships

under DLI 4 Healthcare Management Review Volume 13

PAGE

110

The National Health Act (NHAct) NHIS - Social Health Insurance Scheme NSHDP 2016-2020 MDGs Post 2015 Development Agenda Universal Health Coverage

Ÿ Where this is yet to be done, establish State Primary Healthcare Development Agencies

(SPHCDAs) as a way of consolidating the management of the PHC system: Transfer PHC health workers to SPHCDA – DLI 5 Start tracking PHC budget and its execution – DLI 5 Ensure funds from SOML PforR used for PHC Ÿ Produce and publish a consolidated budget execution report covering all income and

expenditure for PHC Ÿ Immediately after the NCH, zonal and state workshop would take place with the PMU and

the WB in order to ﬁnalise the state’s work plan towards funds disbursement; Ÿ Include in your transition plan for the new governments the central role of SOML P4R Ÿ IDPs in Nigeria working in states have agreed to support states in developing such plans

Healthcare Management Review Volume 13

PAGE

111

BLAKE

MYCOSKIE Founder and Chief Shoe Giver of Toms,

Healthcare Management Review Volume 13

PAGE

112

INNOVATIVE PHILANTHROPY ONE FOR ONE Blake Mycoskie is a visionary social entrepreneur, whose idea of one for one is changing how companies view their corporate social responsibilities and how consumers can use their purchasing power to make conscious and impactful choices.

Healthcare Management Review Volume 13

PAGE

113

Social

Entrepreneurship

ocial entrepreneurship reflects a new way of thinking about success, defined by work that fulfils hunger for material accomplishment, philanthropic impact and personal meaning. “While travelling in Argentina in 2006, Blake witnessed the hardships faces by children growing up without shoes. His solution to the problem was simple, yet revolutionary: to create for profit business that was sustainable and not reliant

In an effort to inspire evermore social entrepreneurs, Blake has written the best seller book: Starting Something that Matters. Toms is committed to more than just giving. They go beyond one for one. Over the last eight years, Toms have identiﬁed ﬁve keys ways of helping people and communities around the world to succeed. Ÿ

Toms is helping in job creation by establishing manufacturing and sourcing in countries where they give.

Toms is helping new social enterprises get their start from the ground up.

Toms giving is integrated into the local giving partner programs, contributing to an entire community's access to health education and well being.

Along Toms journey, they have built a giving team, supported eradication of disease and launched cause-related products to support and raise money for organizations around the world.

on donations. The model comprised of a commitment to donate one pair of shoes for every pair purchased and has resulted in over 10million pairs of new shoes for children in need since Toms was founded.” Through founding Toms, Mycoskie has developed one of the most innovative and engaging business models to emerge in recent years. He has since extended the one for one model for Toms eyewear in which for every eyewear purchased, Toms would give sight to a person in need, and he plans to extend it. Most recently, Blake has signaled another reinvention or his company from one focused on donating aid to one that also aims to provide sustainable growth opportunities for people in developing countries. By the end of 2015, Toms moved one third of shoes produced in the countries to which the company donates.

Toms Program Integration “Toms giving products and services are a small part of the large community development programmes run by our giving partners. We relate to them as the experts in the ﬁeld, who put Tom's shoes, sight, water, safe birth and bully prevention services to the best use.” Healthcare Management Review Volume 13

PAGE

114

Toms welcomes the opportunity to join forces with incredible organizations around the world, whose integrated approaches across health, education and other service sectors allows us to provide a valuable link through Toms giving. Blake Mycoskie

Improving lives With every product you purchase, TOMS will help a person in need. One for One.® IT ALL BEGINS WITH YOUR

Purchase

Sales of TOMS Shoes, Eyewear, Bags and Roasting Co. ® Coffee drive Giving through our One for One model. Every time a TOMS product is purchased, a person in need is helped.

Sustainable Giving Partners work with communities to address their needs in a way that will enable the community to meet its own needs in the future.

Local We seek locally staffed and led organizations that have a long-term commitment to the regions where they work.

Need TOMS' support furthers our Giving Partners' long-term goals and is integrated into their programs.

Evolving TOMS is committed to improving our Giving by continually evolving. We look for partners who can report back to us on how we can improve.

Neutral TOMS products and services are provided to help people in need. Our partners do not distribute them with any religious or political afﬁliations.

Healthcare Management Review Volume 13

PAGE

115

YOUSELINE'S SAFER BIRTH STORY IN

HAITI

Purchases of the newest TOMS One for OneÂŽ, the TOMS Bag Collection, help Giving Partners like UNFPA provide training for skilled birth attendants and distribute birth kits full of items that can help a woman safely give birth, even in diďŹ&#x192;cult circumstances. With the support of your purchases, we're addressing the global need for advancements in maternal health.

HOW SAFE BIRTH GIVING WORKS STEP 1:

MATCH FUNDS We use money from TOMS Bags purchases to support our Giving Partners' programs in maternal health.

STEP 2:

PROVIDE TRAINING + MATERIALS Community health workers are trained on safe birth practices and given the materials needed to help provide a safe birth. These skilled birth attendants then visit expectant mothers in their communities to monitor their pregnancies.

STEP 3:

SAVE LIVES With training and proper materials to provide a safer delivery, mothers are up to 80% less likely to develop an infection. Almost half of newborn deaths can be prevented. Healthcare Management Review Volume 13

PAGE

116

With thesupport of your purchases, we're addressing the global need for advancements in maternal health.

Meet Youseline, a woman in Haiti who recently had her ďŹ rst child at a clinic supported by TOMS Giving Partner, the United Nations Population Fund (UNFPA)

By providing clean birth conditions and skilled birth attendants, nearly half a million lives can be saved each year (Source: UNFPA & Every Newborn Action Plan, 2014). To help save these lives, UNFPA works to build a world where every pregnancy is wanted and every birth is safe. Since it began work in 1969, the number of women dying from complications at childbirth has halved. Healthcare Management Review Volume 13

PAGE

117

Thinking outside the shoe box

The founder of Toms is thinking outside the shoebox - though he's learned the hard way that some things can't be disrupted. -As told to Scott Gerber Your company is an icon of conscious capitalism. What's been the key to its success? Our "One for One" model-we donate a pair of shoes for every pair we sell--is easy for customers to understand. It's empowering, and customers share it with the people they know, which leads to more customers. We launched in 2006, just as Facebook and YouTube were really taking off, and that helped us too.

What have you learned about disruption? When I started Toms, I wanted to eliminate shoe boxes, which create a lot of waste. So we started selling our shoes in recyclable canvas bags. But retailers' stockrooms are set up for boxes. The canvas bags created so many problems that clerks would tell customers that the Toms shoes were sold out, and sell them something else, because they didn't want to deal with the tangled mess created by drawstring bags. We almost went out of business. So now we do boxes. It was a very humbling experience. Healthcare Management Review Volume 13

PAGE

118

Blake Mycoskie

an icon of conscious capitalism You've expanded from shoes to eyeglasses to coﬀee. What does it take to make such leaps?

Will your for-proﬁt form of philanthropy displace nonproﬁts?

People connect with us because buying Toms is like a badge that says, "I did something for someone." If we can give customers the feeling of giving back, we can extend into Toms Hotels or Toms Banking or other ideas we haven't come up with yet, because the One for One model can be relevant to many things consumers do.

Many causes make sense for non-profits. Take human trafficking: I don't see an anti-trafficking organization having a product to sell or any reason to be a for-profit. But as a for-profit, I can make smart bets on marketing and talent that will allow us to do a lot of good over time, because I am not scrutinized about how I spend money in the same way that non-profits are. There is a need for both.

Healthcare Management Review Volume 13

PAGE

119

IS YOUR HEALTHCARE ORGANIZATION READY FOR THE CHALLENGE AHEAD? PPPs in Health is the answer

...It is also the question. What kind? How to do? How to manage? How to make it work within your context? PPP in Health Nigeria Conference WILL HELP YOU ANSWER THESE QUESTIONS

A transformational experience for results-focused healthcare leaders and investors 22-23rd March, 2016, Nicon Luxury Hotel, Abuja-Nigeria es t iv

th care xecu E

Federal Ministry of Health

Hea

Infrastructure Concession Regulatory Commission

a Colleg ov

THE PRESIDENCY

WORKING PARTNERS

Rova College Healthcare Executives Executive Education

For Further information contact the conference coordinator 08087504372, 08033247431 rova_healthmgt@yahoo.com, pppsinhealthnig@yahoo.com 08035949524 bolaolowu2004@yahoo.com