NIPSS-PAS Study Tour: Attaining Universal Health Coverage in Nigeria, the Lagos Example

As a sequel to the local study tour of Niger state, members of study group five of the Senior Executive Couse (SEC) 41 at the National Institute for Policy and Strategic Studies (NIPSS) were in Lagos  state (May 13th  to 18th) where they understudied the state’s model healthcare system, in partial fulfillment of their Presidential Mandate of researching and advising the Nigerian government on the most effective strategies for funding healthcare delivery towards attaining Universal Healthcare Coverage (UHC) in Nigeria

 

Lagos, the acclaimed mega city of aquatic splendor and limitless of opportunities, is a behemoth: Nigeria’s former administrative capital, its current commercial capital and Africa’s most populous city with a projected population of over 24 million people, and many more. Although just one of the 36 states that made up the Nigerian federation, its towering position – economic might, level of advancement and strategic location on the edge of the Atlantic Ocean – gives Lagos the false image of a city-state.

Lagos is thus always a step or more ahead of other Nigerian states in almost everything: economy, education, healthcare, governance, legal system, tourism and infrastructure, making it a mecca of sort for leaders of other Nigerian states who come to Lagos on study tours and learning visits, every now and then. Therefore, its choice as one of the 12 Nigerian states to be understudied by members of the Senior Executive Course (SEC) 41 of the National Institute for Policy and Strategic Studies (NIPSS) was almost a natural one.

Like they did in Niger state, members of study group five of NIPSS SEC 41 were in Lagos to understudy its model healthcare system, in partial fulfillment of their Presidential Mandate of researching and advising the Nigerian government on the most effective strategies for funding healthcare delivery towards attaining Universal Healthcare Coverage (UHC) in Nigeria. Beginning from 1999, the Lagos State Government has experimented with many policy initiatives aimed at advancing the attainment of Universal Health Coverage among its unmatched population. However, even for almighty Lagos, the journey towards UHC has not been without hitches.

Lagos had over the last two decades introduced many schemes, established laws and agencies aimed at strengthening its healthcare system such as the Free Health Scheme; the Community-Based Health Insurance Scheme (CBHIS); and the Lagos State Health Facility Monitoring and Accreditation Agency (HEFAMAA). Most importantly, there is  the  Lagos State Health Scheme (LSHS) which comprises of the Lagos State Health Management Agency (LASHMA) and the Lagos State Health Fund (LASHEF). All these schemes and institutions are aimed at improving service delivery towards achieving Universal Health Coverage (UHC).

 

Funding Universal Health Coverage in Lagos

At the dawn of democracy in 1999, the Lagos State Government experimented with its first attempt at ensuring access to quality healthcare for all its citizens, in the form of the Free Health Scheme. The scheme had particularly targeted members of vulnerable groups such as children under the age of 12 years; elderly citizens of over 60 years of age as well as indigent residents of Lagos state. Although the scheme was meant to ensure access to quality healthcare for the poor and vulnerable in Lagos state, it was barely able to achieve its desired objectives.

Thus, it was the failure of the Free Health Scheme in Lagos that compelled the establishment of the Lagos State Health Scheme (LSHS), as a health financing policy replacing the Free Health Scheme, signed into law in May, 2015. The LSHS law established the Lagos State Health Management Agency (LASHMA) whose mandate is promoting, regulating, supervising and ensuring the effective administration of the LSHS – being part of which is compulsory for all residents of the state.

The Law also establishes the Lagos State Health Fund (LASHEF) which serves as a basket of funds for the provision of healthcare services for the enrolled population under LSHS, with funding sources being the 1% of the Consolidated Revenue Fund (CRF) of the Lagos State Government; premium payments by residents in formal and informal sectors; donations and grants-in-aid as well as funds from the Federal Government of Nigeria through the two funding gateways of the National Health Insurance Scheme (NHIS) and National Primary Health Care Development Agency (NPHCDA), as statutorily provided for by the Federal Government’s Basic Health Care Provision Fund (BHCPF).

Amongst others, the LSHS is intended to provide protection to Lagosians from the financial hardship of huge medical bills; address issues of physical access to quality and affordable healthcare services; ensure the poor and vulnerable have access to quality healthcare services; as well as improve and harness private sector participation, amongst others.  The premium payment for a family of 2 parents and 4 children of less than 18 years of age is N40, 000 per annum while individuals registering under the scheme are to pay N8, 500 per annum.

Full subsidies are accorded the indigent population thanks to the 1% CRF of the state while state civil servants enjoy 75% subsidy on their premium, which is paid on their behalf by the state government. The observable deficiency of this funding framework is that the LSHS requires all enrollees under the scheme including state civil servants – and with the exception of the poor and indigent – to pay a uniform premium of N40, 000 per annum (per family) and N8,500 per annum (per individual). This clearly negates the basic principles of social health insurance schemes which are built on the premise of equitable contributions (on the basis of income level) and cross-subsidization of contributions.

Dr Nasirdeen Usman, the acting director of studies at the National Institute for Policy and Strategic Studies (NIPSS) cum head of the study group five of SEC 41, shares this sentiment. He believes although Lagos had done well in terms of putting in place policies that will guarantee sustainable funding for healthcare delivery, the premium charges should be a percentage of the gross salaries of contributors – and not a flat rate.

“My own fair assessment is: Lagos has made good strides in the area of funding healthcare delivery; however, there is need for them to go back to the drawing board and fine-tune some things. For example, the flat premium rates whereby whether you are rich or poor you pay the same amount. It means, in the civil service, whether you are a permanent secretary or clerk you have to pay the same amount; I think it should be a factor of percentage of your gross salary and that way, they will be able to raise more funds,” he proposed.

Dr Obioma Obikeze , a health economist and health financing expert, who was the dRPC-PAS consultant for the Lagos leg of the study tour also believes the Lagos flat-rate premium charges negate the principles of social health insurance schemes which are built on the premise of equitable contributions (on the basis of income level) and cross-subsidization of contributions, disease burden and age, as being promoted by the World Health Organisation and World Bank.

“The backbone of social health insurance is having cross-subsidization of contributions, disease burden and age so that the monies of those who are well today are used to take care of those who are sick today – and they do not mind in the spirit of solidarity, they know that one day it will be their turn to fall sick. The monies of the young who are less likely to be sick will pay for the old who are more likely to be sick. A grade level one officer should pay according to his income while the permanent secretary should also pay according to his income. For example, it is much more difficult for a woman with 4 children, who is earning less than N20, 000 as salary to pay N10, 000 compared to a permanent secretary who is earning N400, 000,” said Dr Obikeze.

He believes as much as the Lagos State Government meant well in establishing the Lagos State Health Scheme (LSHS); nonetheless, the scheme would only be made robust and effective, if contributions were made relative to people’s earning power, which he said would also help the scheme raise more funds.

“I think it will be better if they make the contributions relative to earning; it will help the system raise more funds. Much as the state means well, the system of raising revenue does not guarantee equity for all stakeholders; they need to have a rethink of their revenue raising model because of the inherent inequity in it. One of the problems social health insurance is meant to solve is equity of access to care such that everyone contributes according to their ability but receive care according to their [specific] needs,” said Obikeze.

 

Lagos’ experimentation with Community-Based Health Insurance Scheme

Lagos State Commissioner of Health Dr Jide Idris, while briefing the NIPSS-PAS study tour team on the Community-Based Health Insurance Scheme (CBHIS) recalled that the Lagos State Government had as part of its CBHIS launched the Ikosi-Isheri Mutual Health Plan, in July 2008.  He said the major aim of the scheme which targeted the informal sector was “improving the performance of the health sector in terms of accessibility, availability, quality, equity and affordability of healthcare in the State.”

The rationale for the scheme which was piloted in 4 LGAs of the state was addressing the informal sector (poor and vulnerable); engendering community involvement; and fostering collaboration between the Lagos State Government and its 20 LGAs. Others were addressing the Human Resource for Health (HRH) gap; leveraging private sector resources; as well as addressing the issue of access to health services at primary healthcare (PHC) level.

“The scheme was subsidized by the state government, it offered primary healthcare services to all enrolled members of the community and was managed by the elected Board of Trustees (BOT) drawn mostly from the community. Premium was N1200 per month for a family of 6 – it was initially N800 at the pilot stage of the scheme. For any additional member of the family (for families that exceed six members) it was N300 per month. The BOT had an administrative office which was responsible for the enrolment, funds collection and enrolment data generation while the ministry [of health] played oversight functions,” said Dr Idris.

He however said the CBHIS faced many challenges such as poor understanding of health insurance amongst the community members; poor support from the leadership of the Local Government Areas (LGAs) and Local Council Development Authorities (LCDAs) as well as inadequate monitoring and evaluation. Yet, he said they learnt many lessons from the implementation of the scheme such as the fact that people were willing to pay for insurance, once they were assured of quality of service; the necessity of continuous engagement of all stakeholders in the scheme; and that the voluntary nature of the scheme was a major constraint to its uptake.

It was these lessons that guided Lagos in developing its social health insurance scheme, in line with NHIS’s provisions that states could implement a State-supported Social Health Insurance Scheme (SSHIS), which paved the way for the establishment of the Lagos State Health Scheme (LSHS) in 2015, formal access to care under the scheme was launched in December 2018.

Dr Nasirdeen Usman of NIPSS critiqued the fact that Community-Based Health Insurance Scheme (CBHIS) was still not integrated in the Lagos State Health Scheme, which was due to an assumption by the Lagos State Government that if they commenced implementation of the LSHS with the Community-Based Health Insurance  (CBHI) component, the whole scheme will collapse. “What I find a bit curious is the fact there is no specific provision for CBHI; they assume that if they start with the CBHI, the whole scheme will collapse but there is need to incorporate it. This is because hard-to-reach and rural communities have specific peculiarities in terms of their earning capacity and health needs.”

 

The Lagos State Health Scheme (LSHS)

The Lagos State Health Scheme (LSHS) is state-wide, prepaid and mandatory for all Lagos state residents; it is aimed at reducing out-of-pocket expenses of health-seeking residents of Lagos. The implementation of the scheme is under the supervision and coordination of the Lagos State Health Management Agency (LASHMA). Already, 150 private facilities and 44 public facilities have been registered to provide care under the scheme while enrollees are given the choice of where they can access care: private or public facilities. This means unsatisfied enrollees can always change their care providers.

The LSHS has benefit packages covering basic health services available at primary healthcare level as well as selected secondary healthcare services. Currently, the Scheme comprises of 3 health plans which include the Lagos State Health Plan which offers a defined minimum benefit package of primary healthcare services as well as an “affordable” supplementary benefit package for secondary and tertiary healthcare services.

The two other plans which are to be implemented in the short and medium term are (first) the Formal Sector Plan: a contributory plan for all public and private sector employees where the employers and employees make contributions as may be determined by the Governing Board of LASHMA and (second) the Lagos State Private Health Plan: a variety of packages providing healthcare services in direct proportion to the contribution made.

Speaking on the LSHS, Dr Nasirdeen Usman said Lagos state was unique and better-positioned economically to implement a social health insurance scheme, compared to other Nigerian states, applauding the state for learning from and managing to avoid the pitfalls that the National Health Insurance Scheme (NHIS) had found itself deeply into in its engagement of Health Maintenance Organisations (HMOs) who act as “middle men” between NHIS and care providers.

“Their health insurance scheme has all sorts of layers of control, overseeing the operationalization of the scheme. The scheme has also curtailed the powers of the HMOs who are sabotaging the NHIS by withholding funds from NHIS and not providing same to the healthcare providers. Instead, in Lagos, the HMOs are engaged as Health Insurance Agents (HIAs) whose role is basically marketing the scheme for which they are paid commission. Lagos has learnt from the pitfalls associated with the operationalization of the NHIS,” he said.

A look at the primary healthcare system in Lagos

Although the LSHS is already operational and the primary healthcare system in Lagos is supposed to be under a single authority, based on the Primary Health Care Under One Roof (PHCUOR) policy of the Federal Government of Nigeria, it was obvious that PHC was far from being under one roof and was rather fragmented. For example, while on study tour of selected PHCs such as the Mushin Health Centre and Comprehensive Primary Healthcare Centre, Aboru, the NIPSS-PAS team discovered several discrepancies including multiple sources of funding coming to the facilities.

Lagos obviously need to streamline the management, governance and funding of PHC under the State Pimary Health Care Development Agency (SPHCDA), in accordance with the PHCUOR policy.

While sharing his thoughts on the state of the primary healthcare centres (PHCs) in Lagos state, Dr Nasirdeen Usman described it as “a mix of good and not so good” adding that whereas some of the PHCs had a very good number and quality staff including doctors, nurses and other complimentary staff; other PHCs  still needed more staffing. He said since social insurance was about trust, the PHCs needed to be seriously repositioned in terms of adequate staffing, equipment and other basic facilities so that enrollees would be able to satisfactorily receive the Basic Minimum Package of Health Services (BMPHS), which will boost their confidence about the LSHS.

“The funding system is not good enough; internally generated revenue from the PHCs is first deposited in the LGA account and then the LGA will pay the PHCs subventions which is ridiculous; as low as 50,000 per month. This means it is possible that the LGA officials are tempering with the funds of the PHCs. So, there is need to address the funding challenge; probably that will be naturally addressed when the BHCPF became fully operational and each PHC got their own bank accounts that will be managed independently,” he said.

Dr Obioma Obikeze, the dRPC-PAS consultant, describes the condition in some of the PHCs in Lagos as more sophisticated than what was obtainable in PHCs in other parts of Nigeria; he however decries the fact that there were still no equitable distribution of functional PHCs across the state, since 100 out of the 302 PHCs in the state were still not properly functioning.

“I must concede the fact that some of the PHCs in Lagos are more sophisticated than PHCs in other parts of the country; I saw a comprehensive approach to PHC delivery – doctors, nurses, and laboratory scientists working in PHCs. I therefore must say Lagos has gone ahead of others in laying the foundation for PHC delivery. However, there is still no equitable distribution of PHCs – 100 out of the 302 PHCs are still not functional. That means not every ward has a functional PHC; how do you cover these areas in terms of immunization, for example? So, there is still need for them to ensure equity in terms of access to healthcare,” he said.

Dr Obikeze also cautions the Lagos State Government on its adoption of Public Private Partnership (PPP) in running some of its PHCs so as to ensure maximum benefits through such partnership; he also hopes the implementation of the Basic Healthcare Provision Fund (BHCPF) in Lagos state would help the state revitalize its PHC system and ensure availability and accessibility of BMPHS across its PHCs.

“Beyond engaging private investors to renovate and operate the PHCs, there is need to institute a performance-based contracting (PBC) mechanism. There is need for a set of specific deliverables around coverage for Family Planning, Routine Immunization and numbers of women successfully delivering at the PHCs. The state will get more value for money by doing so; if you don’t tie funds to performance indicators they (private investors) may not necessarily deliver the maximum satisfaction. These measures will ensure enrollees do not opt out of the scheme and providers do not take advantage of it,” he advised.

 

PPP: An innovative strategy for financing UHC in Lagos

Unlike any other state of the federation, Lagos boasts of a huge and vibrant private sector hence the state is leveraging the existence of private healthcare providers to outsource primary, secondary and tertiary healthcare needs of its teeming populace. Under an initiative called Access to Finance (A2F), the Lagos State Ministry of Health, the PharmAccess Foundation and Lagos State Ministry of Wealth Creation and Employment, on one hand, are currently engaged in a partnership with the Lagos State Employment Trust Fund, Bank of Industry (BOI) and select commercial banks, on the other hand, with a view to outsourcing 43 sub-optimally functioning primary healthcare centres to private organizations, in a PPP arrangement.

“The private health sector provides over 65% of healthcare services in Lagos. Small and medium enterprises in the healthcare space (Health SMEs) constitute the majority of private healthcare providers. The propagation and growth of these Health SMEs has been greatly stunted as they are mostly underfunded and unable to attract investment capital. Therefore, Lagos state ministries of health as well as wealth creation and employment, in partnership with PharmAccess Group and the Medical Credit Fund (MCF), developed a framework where Health SMEs in Lagos are given access to cheaper funding to facilitate their expansion while creating employment within Lagos State,” said Dr Idris

“The total funding pool will be given out as loans to Health SMEs in installments. All facilities under the framework would be mandatorily made to adopt the SafeCare methodology with oversight from the health facility monitoring and accreditation agency. 43 semi-functional and abandoned primary healthcare centres were allotted to experienced private sector providers to revitalize and operate for a set period. The scheme created an enabling environment by providing single digit loans (9.5%) in partnership with the Lagos State Employment Trust Fund, the Bank of Industry and other commercial banks; with MCF providing technical assistance and the partial risk share guarantee on the loans.”

The A2F is now in its pilot stage, the plan is to get more PHCs outsourced to private investors so as to reposition them to be better able to provide services under the Lagos State Health Scheme towards ensuring the availability of quality healthcare services in Lagos state. Thanks to various partnerships with private companies, the state is now able to provide quality specialized healthcare services in areas it doesn’t have the capacity to provide itself. Critically-important healthcare services such as blood transfusion, histopathology, mammography and CT scan; dialysis; as well as helicopter-based emergency medical response are currently being provided by private investors across state owned facilities, under a PPP arrangement.

“Bringing in the private providers to provide care offers an opportunity for choice to the clients; it is a global best practice which will ensure healthy competition between public and private healthcare facilities and also among the private facilities themselves,” said Dr Obikeze. “When that happens, the government will be made to upgrade its own facilities since the more qualitative your service, the more enrollees you will get and also the bigger your capitation. So, it is a competition, let the best win the game! That is the best model. In most countries, the public-private mix is responsible for the success of social insurance schemes.”

 

 

Integrating traditional medicine in Lagos’ healthcare system

Established in 1980, the Lagos State Traditional Medicine Board (LSTMB) is the agency responsible for regulating, promoting, monitoring and integrating traditional medicine practice in the state. According to Kadiku Olawale Olorunkemi, coordinating director of LSTMB, while addressing the NIPSS-PAS delegation on the role of traditional medicine in achieving UHC in Lagos state, “80% of Africans received the bulk of their healthcare from traditional medicine practitioners as compared with healthcare received from primary care clinicians.”

“The health seeking behavior of Africans makes traditional medicine practitioners their first point of contact in seeking solution to their health challenges based on various reasons such as religious and sociocultural beliefs, social norms, flexible payment methods, provision of psychosocial support, availability, accessibility and affordability… In Lagos State, as at today, there are over six thousand registered alternative medicine practitioners, these alternative medicine practitioners offer a wide range of services in the healthcare delivery system which includes child and maternal care, orthopaedic treatments, amongst a host of others,” he said.

Olorunkemi, however noted that the relationship between traditional or rather alternative medicine practitioners and conventional medicine practitioners had not been collaborative, in Lagos state, which he said was a result of wrongly held opinion by conventional medicine practitioners – that complementary medicine practitioners were “unscientific and unethical”.

“Consequently, alternative medicine practitioners are marginalized in the healthcare delivery system in terms of funding, capacity building, and involvement in programmes conception and implementation. As compared with developed world i.e Germany, France, United Kingdom e.t.c, alternative medicine practice in Lagos State and the country represents a substantial, largely untapped resource base and unrealised sector of the healthcare delivery system. The alternative medicine practice is a multi- billion dollar business in China, India, Turkey and the money generated yearly is bigger than the size of the budget of many countries in Africa,” he noted.

Olorunkemi said although the major argument from the practitioners of conventional medicine was to do with the efficacy and effectiveness of alternative medicine, in 2013, the West Africa Health Organization (WAHO) had mandated all ECOWAS member states to train traditional medicine practitioners on the use of herbs in the management of six priority diseases: diabetes, hypertension, TB, HIV/ AIDS, sickle cell anemia and malaria. This, he said, had greatly assisted the standardization of herbal medicine including addressing issues to do with proper administration and dosage thereby enabling the effective management of the six priority diseases.

“The effectiveness of the healthcare delivery system is determined by the availability of human resources, presently, there is shortage of skilled healthcare workforce in Nigeria and Lagos state as a result of high rate of migration, insufficient number of medical graduates, inadequate medical facilities, amongst other factors. Primary health facilities and general hospitals are insufficient to provide healthcare services to the teeming population, therefore, a large number of people patronize alternative medicine practitioners,” he said.

While speaking on the potential role of traditional medicine in achieving UHC in Nigeria, Dr Nasirdeen Usman said traditional medicine was already playing a significant role in the country’s healthcare system especially at rural level, where it was already the first-port-of -call. He added that even among the elites, recourse was some time being made to traditional medicine and underscored the fact that the sector was largely  “uncoordinated and unregulated”  as its major challenge.

“Asian countries like China and India have put a lot of emphasis on integrating traditional medicine into their healthcare system; I think we cannot run away from it in this country, otherwise we will just be playing the ostrich. The major attraction to the traditional medicine system is its informality; you can go to the house of a traditional doctor at any time, it is also cheap compared to orthodox medicine. There is need for a deliberate effort on the part of government in terms of investing in research and development. However, government needs to put a lot of emphasis on regulation; there are lots of quacks in the system and challenges with administration and dosage,” he urged.

Dr Obioma Obikeze agrees. He sues for what he calls “a meeting point” between the orthodox and unorthodox medicines.  “It is a wonderful idea, there is need for a meeting point between the orthodox and so-called unorthodox medicines; they (traditional medicine practitioners) have a value to bring to the table but mutual suspicion and ego appears to be the issue. Our grand and great-grand parents were surviving before orthodox medicine came. So, we can learn from each other, there are lots of meeting points; however, there is need for regulation because a number of people masquerading as traditional medicine practitioners are actually quacks. There is need for openness and reduction of mutual suspicion.”