Our mission is to achieve universal health coverage for all Edo citizens and residents – Dr. Amegor

Dr. Rock Ilelosa Amegor, an alumnus of the London School of Economics and an established General Practitioner with extensive hands-on experience in nonprofit and public sector environments, is the Director General, Edo State Health Insurance Commission. In this interview with Edward Oseghe and Jennifer Osadoh, Dr. Amegor speaks on the Commission’s mandate, what it has achieved so far, and the plans ahead.

What is the Edo Health Insurance Commission all about? What does the Commission do?

I will start from the basics. In 2017, a technical committee or a technical working group was set up by His Excellency, Governor Godwin Obaseki, to bring up laws that will guide and give direction to the Edo State Health Insurance Commission. So they worked for two years, and in 2019, the law was drafted.

I was employed that same year. When we came into the system, the first thing we did was to look at the needs assessment of the people and also to check the facilities that this service would be giving. And then, we realized that people did not have trust in most of the public facilities. There was a lot of decay, and the manpower deficit was ravishing the primary health agencies. And so, we set up criteria at the time, in 2020, to make sure people can now function optimally within the healthcare system. But at the time we set up the criteria, out of the first set of 52 hospitals we had visited, no one passed the criteria. Thus, we thought that we should domesticate our criteria and align them with present-day reality. So we rejigged our criteria again and said, okay, we would bring them up to speed; we would reduce it so that the baseline won’t be that high, but we expect that they will not stop where they started. They continue moving forward. And so, we set up minimal criteria for manpower. We set up non-clinical services as it relates to primary health care, which include water, alternate power supply, adequate nursing security, and all that.

We began to get enrollees to start functioning within these primary health care centres. What we did was that we made sure the heads of most of these primary health care centres (PHCs) had some form of financial literacy, because, as you know, we are a health insurance body. We give them claims based on people who come to visit the facility.

We gave them some financial health literacy such that when there are problems within the facility, they’ll be able to meet short and immediate-term gaps. The very first thing we did was that we made sure every facility and panel under the scheme developed what we call the Quality Improvement Team, and this quality improvement team comprised people within the facility, those within the community, and also the enrollees.

We knew that if the facilities had to survive, they had to take ownership. Then they had to have a form of assembly, if you like. If you remember, in the old Roman Empire, they had a direct assembly where people would gather and talk about what they wanted and that’s how they were able to democratize Rome.

So, we took a perspective from what they did in the old Roman Empire and said this quality improvement team will consist of these various people to talk about their pain points, and what is most desirable for them. Of course, we cannot solve all the problems at once. So these people met, we would give them criteria to meet every week, once weekly, to say what they needed to do. Based on the resources they had, what could they fix, what could they achieve, and how could they optimize their processes? They started and we found out that in six months our results were outstanding.

PHCs that were dilapidated now started fixing their rooms because we gave them a sort of autonomy through direct facility funding. Yes, they had to submit a work plan of what they needed to do, but they had to follow those steps. And so, we gave them autonomy not to go and do contractual services, but a direct buy from the market so that if a bulb is broken, you don’t have to go and do a contract. You go as a nurse or as a head of the facility to go and buy the bulb. If your net is torn, you go and look at what money you have within your purview. You bring your team together and say, okay, we need to do this.

Most of them began to democratize their health services and so we began to see a lot of improvement. What we are doing now is that we’re almost bringing equality and equity to most of the PHCs. They are now competing favourably with the private providers and they are getting better. We know that before the end of next year, a lot of them would have come up to speed. When we started, less than one-sixth of them were optimal. But we can say almost half of them now have come to speed. By doing this over and over, ensuring adequate quality and monitoring and also evaluation routinely and on schedule, they would be able to bring their processes to at least function in an optimal way.

This health insurance scheme, what does it offer?

What we have done is that we have tried to make the health scheme inclusive in terms of people who provide care, from primary level care to secondary level care to pharmaceutical care, diagnostics, and all cadres of care. At present, the health market in Edo State is priced at about $240,000,000, and what we can assess is less than 5-10 per cent of that. So, what the health insurance is doing is trying to consolidate most of these health schemes to bring them under one roof, if you like, such that the services they give across the board will be standardized. The pricing of services will be standardized. A lot of people can now get health care by paying a minimal amount of premium into our scheme, and they get better health care. It’s an all-inclusive process. The healthcare service providers submit their claims at the end of the month and we reach out to some of our enrollees to ask, was this service given to you?

I will give you a hypothetical situation. You go to a facility, for example, there’s somebody who’s going to give you a prescription, say, I have a headache or malaria. That prescription is going to come in three duplicates. The facility keeps one, the enrollee keeps one, and they send one to the insurance commission. So, if as an enrollee, they write five drugs and they dispense only two to you, you’re not going to sign it off. You are going to know that, oh, there was a deficit in these drugs. That’s how we monitor claims to make sure we do not pay for services or drugs that were not given.

And to make it more inclusive, we did implementation research and saw that a lot of facilities, what they do is that they say they have stock out. So primary drugs, we pay the facilities on time. If you are an enrollee, whether you are sick or not, we pay the facility on your behalf monthly. It’s called capitation. Because some drugs are capitated, we find out that some of the facilities say these drugs are not within stock because we’ve paid for them on time. So, we also devised a way to catch them. When those drugs are capitated and they don’t give our enrollees those drugs, our enrollees now take their prescription, remember, I said it comes in duplicates. They take this prescription to any of our empowered pharmacists across the state, and they collect those drugs. Of course, you know that the prescription is going to come with the hospital name and the name of the enrollee, and so we’re able to trace when the claims come at the end of the month that a particular capitated drug was not given to this enrollee, and he went to another facility to get it. At the back end, you almost are now within the health insurance commission to say, okay, facility A did not have these drugs, but the pharmaceutical had the drug. It was one of the essential drugs that the facility was supposed to give. So, we minus the money we are supposed to give to them the next month and make sure that the enrollees are happy. What we are doing is an enrollee or patient-centric care so that the customers go home feeling satisfied and have a positive experience anytime they visit most of our facilities.

Who does the scheme cover? Is it just government workers or can anybody access it?

That’s a beautiful question because every time you hear of health insurance, it sounds very elitist. You hear, ‘Oh, only people that are educated; only for those working within the government’. If you see the percentage of those working within government, it’s about 20 per cent of the total coverage we have today. The bulk of the people that exist are outside the non-government workers. What we did was that we said charity begins at home, and so we started covering our government workers first. In that instance, we were doing deductions from their salaries. We tried to achieve equality and equity across the board. We’re deducting 1.75 per cent of gross salary from every worker. So, if you are a worker in Edo State, if you ask for your paycheck, you will see a part that says health insurance deduction of 1.75 per cent of your gross salary, but that in itself is not enough to cover for your health care. And so the Obaseki government was magnanimous to say whatever an enrollee pays for health care, we will match it. So if, for example, you are contributing N5,000 of your salary to the health insurance, the governor is also contributing another N5,000 on your behalf. If you look at Grade Level 11 down to 17, those who are on a higher cadre, they contribute more because of the percentage base, but those who are on the lower cadre – cleaners, drivers, etc – contribute less but also get the same amount of care. We don’t get to say because you’re in Grade Level 3, go to a particular hospital.

So, it’s health care across everybody, universal health care, and it can cover father, mother and four children less than 18 years of age. That’s for those working within the government’s purview.

Now, if you’re not an employee of the government, you’re an individual, we have plans ranging from N18,000 to N75,000. The Bronze plan is N18,000, the Silver plan is N35,000, the Gold plan is N68,000, and the Platinum is N75,000. For all these plans, as they are increasing, your benefits are increasing.

But what we try to do across the board is to check for maternal mortality and child mortality. Whether you are paying N18,000 or N75,000, if you have a case, say, you have an ectopic pregnancy and it gets down to a CS, I’m not going to say because you paid N18,000 we’re not going to cover your CS fully. We don’t want our mothers to die and we don’t want our children to die. So, as it were, the government covers the father, mother, and four children. But the prices I gave you for the premium cover individual plan.

Now, as a family, if you want to join the scheme – a family is anybody not just related by blood, but someone who you expect some level of support – you can be an adopted family. When you come in groups as a family, we give you a 5 per cent discount just to encourage familyhood, brotherhood, sisterhood, where people can work together as one unit.

Does that apply to government workers too?

Yes. The government workers, we have grouped them as a family to say, once we are doing deductions, it covers you as the principal, your husband or wife, as the case may be, and four children less than 18 years of age. We put a cap of 18 years of age because we also have student plans. We hope that at 18 years of age, you go into a tertiary institution or vocational training, where you also have the opportunity of getting health insurance. If you’re in the schools now, we would introduce you to Ambrose Ali University and Igbinedion University which are under the health insurance scheme. But if you’re doing a vocational service, your boss or whoever you’re working with could say, ‘Okay, I’m going to pay for your health insurance, or it’s going to be on a contributory basis. Maybe you bring 50 per cent, I pay 50 per cent’, but that’s dependent on them.

But ours, as a health insurance company, is to make sure these companies that have five employees and above get their people health insurance. If you come to government now, if you want to do most government processes, whether it’s procurement, sales, or just working with the government as an adult, one of the proofs that we put on the ground is that you must join the health insurance team to improve the welfare of Edo residents and citizens.

Let’s say one is coming on board for individuals, is it a one-time payment?

For individuals, it’s a one-time payment for an annual plan. But when we are dealing with government or corporate bodies who have guarantors, sometimes we accept as much as two or three instalments. The reason is that when enrollees are plenty, we are trying to achieve universal coverage. Today we stand at over 200,000 plus, so imagine not using resources to chase one person who’s paying for who has not paid for health insurance. So you will now have more spending on operations than even getting the premium. So we advise that we get a one-off payment, or if a group of people have a catchment in terms of number, then we can then say, okay, pay twice a year, or pay three times a year.

There are cases where some may complain that the budget package does not cover the enrollee’s needs, so oftentimes, they are either rejected or made to pay extra.

If you look at the health ecosystem, it is divided into the supply and the demand side, just like you have in economics. And so, there’s no one particular system that can solve all the problems. So, we expect that the primary health agency, the Ministry of Health, is in charge of the hospitals. And for us, as the Health Insurance Commission, we pay for services.

Having said that, no health insurance agency all over the world can cover every individual’s needs. You have to start and scale. You start with the essential needs of people. If you look at our society, for example, cancers are becoming more and more common, but in the past, it wasn’t very common. So, what we do is that we cover very common illnesses that occur frequently. And so, every year we take statistics of those that people complain about and we start adding them to the benefits. Don’t forget, we started at ground zero. What I mean is that we had no finance at all, and so we started taking money from people and started building our finances.

As a child, you are born to crawl, to sit, to walk, to run, and eventually fly. And that’s what we’re doing in the health insurance space as well. You can’t come and say, we’re going to cover a whole barrage of things, and then you’re not thinking of sustainability in five, six months, you will collapse because you are trying to bite more than you can chew. So, what we do is that we match what we have in our reserve with what present-day society is. One of the things that we have noticed is that most governments and insurance agencies don’t have sustainability; no sustainability plan, and of course, longevity is cut short. That’s one of the things we’re avoiding. We are taking one day at a time, biting as much as we can chew, and then as we are growing, we begin to take more.

How do you cope with the brain drain traffic in Nigeria?

The exodus is almost saddening. Immigration has been part of our existence from the get-go, and so to stop people from not leaving the country is almost impossible. But we are aware that you won’t find a lot of doctors again. I’ve lost five doctors in the past two months. I’ve not been able to replace all of them. We got two by scouting and also with the relationship we’ve had. And a lot of government agencies are facing that now because doctors and nurses are not available.

But one of the innovative ways we have also tried to manage that is to rationalize this health care across the board. You go to a particular area today, go to a particular area the next day, and then we reimburse the doctors and pay for their logistics. If a cardiologist is visiting a particular area, say, with a lot of hypertensive patients, maybe once a week, those within that catchment area will know that a cardiologist is coming and so, they would prepare to go and meet him. So the cardiologist uses that one-stop shop to meet a lot of people.

Other innovative ways are by using telemedicine and telementoring. Doctors who are far and near can give services wherever they are, virtually, just like we have Zoom meetings and other ones. We have started this in Ugbor, Aruogba, every Saturday enrollees come there and there’s a booth where we’ve connected the Internet and they come and they seek healthcare.

Moving forward, we’ll start doing it where they can get health care in the comfort of their home. But every process needs standardization, it needs to be sustainable, it needs to be firm before you move on. And so once that is firm on the ground and we know that the system can sustain itself, then we can start moving to other innovative ways to bring health care to the people.