Ambassador (Dcn.) Theodore Ehannire, the State Coordinator, Edo State National Health Insurance Authority (NHIA) in this interview with EDWARD OSEGHE and IYAYI OWEGIE, speaks on NHIA’s mandate and the structures that are already in place to achieve the universal health coverage plan going forward. Excerpts:
We are aware that the National Health Insurance Authority has the mandate to ensure universal health coverage; can you tell us more about the agency?
As you already know, we used to be National Health Insurance Scheme (NHIS). Right now we are National Health Insurance Authority (NHIA).
We are an institution established by law, by an act of the Federal Government. The act making us an authority was passed into law last year and was signed by former President Mohammed Buhari, and now we are an authority.
We’ve been in the state as a scheme and one basic feature we like to project now that we are an authority is how mandatory our program is.
Hitherto, NHIS was not mandatory, but right now every Nigerian and every legal resident in Nigeria must have health insurance. Whether it’s through the National Health Insurance Authority or the State Social Health Insurance Agency. At least you must have health insurance coverage.
We are working towards universal health coverage. To achieve universal health coverage, only the formal sector will not suffice. Only the Federal Government cannot make it happen. Only the State Government cannot make it happen. So that is why there is a synergy between the NHIA and Edo State, to be precise the EDOHIC (Edo State Health Insurance Commission).
Even if we go formal sector-federal, formal sector-state, it will not achieve universal health coverage.
The informal sector has a larger population and how do we get these people covered? How do we bring them in? Hence, we have designed so many programs. In the National Health Insurance Authority (NHIA) – we have several programs to ensure that no one is left behind.
We have the formal sector Social Health Insurance Program, we have the Tertiary Institution Social Health Insurance Program (TISHIP) – for students in higher institutions. In the informal sector, we have the GIF-SHIP which is the Group, Individual, and Family Social Health Insurance Program.
We have what is called the Basic Healthcare Provision Fund (BHCPF) for the vulnerable. With all these, everybody can have at least a way to enter into the system.
For the federal civil servants, they are already there through the federal programme, for the state, they are already there through the state.
What about our market women, motorcycle riders, and vulcanizers? That’s why we have the Group, Individual, and Family Social Health Insurance Program that can bring them in. They can come in as an individual, as a family, or as a group.
As individuals, when they come in, the maximum number of persons for an individual platform is three. The minimum is one, which means you can come along and say you want to register as an individual, but you will make a payment for three persons because that is the benchmark. You can come as two; you will still make that payment for three people. You can also come as three, which is the maximum. N45, 000 is the benchmark. That N45,000 is supposed to be for three persons. So whether you are one, two, or three, that is the benchmark.
From four to nine is the family, so as you add individuals to the three, also you start adding N15,000 extra. Then for a group, an association, they start from ten and above, and it’s a minimum of N150,000 for a group to whatever number you have, and it goes on like that. That is how we are covering the informal sector.
In the formal sector, the principal, the spouse, and four biological children below the age of 18 are qualified. When a child is above 18 years, we take that child off the platform.
Why do we do this? In the Nigerian constitution, once you are 18 years old, you are no longer a child, you are now an adult. We are not leaving that child behind because the child is 18 years old and is removed. We believe or assume that that child by then should either be in a higher institution or should be in one informal sector working somewhere.
If he’s in a higher institution, then the T-SHIP will cover him. If he’s in the informal sector doing one job or the other, then the GIFSHIP will cover him. In the end, no one is left behind, even the Corps Members are not left behind.
In the GIFSHIP program, we have the GIFSHIP N for the Corps members, the GIFSHIP- R for the retirees, the GIFSHIP – G, which is general, and the GIFSHIP- C, for the constituency.
For the constituency, we are talking with those who have constituency projects like our national assembly members. Yes, this is what we are suggesting and advising them should do. Instead of buying Motorcycles for your constituency members, buy a sewing machine, health is very important, especially now. What we are saying is come to your constituency take about 100 or 200 people, and pay for them. Before you spend 5 million which is not even enough to buy ten motorcycles, you might have covered up to 300 people’s health for a whole year.
I think they would prefer that because I have seen cases where they will be calling their representative. I’m not feeling fine please send money. With N15,000 for one person, you have settled the health needs of that person for a year So that is a constituency project.
I talked about the Basic Healthcare Provision Fund (BHCPF). The Basic Healthcare Provision Fund is a fund that is coming from the Federal Government. It’s coming from at least 1 percent of the Federal Government consolidated revenue budgeted for this. It comes from the National Health Insurance Authority to the State Health Insurance Commission.
Then another part of it comes through the Primary Healthcare Development Agency to the State Primary Healthcare Development Agency. This fund is basically for the vulnerable, and these vulnerable don’t pay anything.
Who are these vulnerable that we are taking care of? These are pregnant women, children under age five, the elderly, the physically challenged, and the poorest of the poor. These are the set of people that the Basic Health Care Provision Fund is taking care of.
You talked about the Basic Healthcare Provision Fund for the vulnerable, how do you determine the vulnerable?
Firstly, for children under the age of five, you don’t need a thermometer to determine their age, neither do you need any thermometer to know a pregnant woman or the physically challenged. All these you can see physically, same with the elderly who are 60 years and above.
I know you are talking about how to know the poorest of the poor. We have what is called the social register. It is from the social register that we get the poorest of the poor.
Some indices are being used when they are registered by the National Social Safety Net Coordinating Office (NASSCO) and the State Social Safety Net Coordinating Office (SOCO). NASSCO is for the nation while SOCO is for the state. They have a template they *use to administer to people.
There are some basic questions they ask. So at the end of it, it is totaled and then you should be able to know whether they fall into the poorest of the poor or not, and that register is reviewed periodically.
Somebody can be vulnerable this year by next year may not be vulnerable. The person can just get a jackpot and leave the vulnerable group. That is how we determine the poorest of the poor.
Secondly, when we started, we made use of the social register. But at times there are some discrepancies because of relocation. So what we now tell them is for the BHCPF, (we use primary healthcare centers because these are closer to the people in the areas). The PHC should register of vulnerable in their catchment to be validated by the authority
With the BHCPF, we are also strengthening the Primary Healthcare Centers (PHCs). If you go around Edo State now you will see that most PHCs are very standard, for this program at least one PHC in every ward in the state is accredited.
What we tell the Officer in Charge (OIC) in the PHCs is, that it is community-driven. The Ward Development Committee (WDC) chairman is a member of the local committee.
So because it is community-driven, the community people know those who are poor in their environment. They know the poor because it’s their program. We have told them, you own the program while we are running the program. You own it so that it can run well. They know the poorest of the poor and it has been going on well.
You made mention of OIC and WDC. For clarity, what are the OIC and WDC?
The OIC (Officer in Charge), is the facility manager. Then the WDC is the Ward Development Committee Chairman in the community.
Every ward has a chairman whatever purpose, be it political or administrative, running the ward, they have a chairman. That chairman is part of the running of the BHCPF in that ward.
You stated that Health insurance is now mandatory in Nigeria, is there any punishment for defaulting?
For now, we are working on the modus operandi for how mandatory health insurance is.
I don’t think we are going to coerce people but there are going to be some things you will be denied from enjoying. I am thinking, for instance, you want to go and register your child in the school. Where is your health insurance card?
You want to assess some government facilities. Where’s your health insurance card? People, who have traveled out of this country say that’s how it’s done. NHS in the UK is compulsory. Once you are doing anything, your NHS must be there. So there are some things you cannot assess without the NHS.
With the way things are going now, people will be running to health insurance.
I want to assume that some persons are not aware of NHIA, so how are you driving awareness?
Thank God the Nigerian Observer is here, and this is the collaboration, we’ve been talking about sensitization. I’m happy that when I became the state coordinator, one of the first establishments of government I visited was The Nigeria Observer, and I did that for a purpose.
I visited Nigeria Observer, I visited NTA (Nigerian Television Authority), I visited EBS (Edo Broadcasting Station), I visited ITV (Independent Television) because these are the major media organizations we have in Edo State. Without media, whatever you are doing, you will just be doing and nobody will know. Whatever the government is doing, nobody will know. That’s why I came to you the other time to let you know that we are on ground.
The last time we did social marketing we went to Ekiosa, and there, most people don’t even know whether there is anything like health insurance. When we came, they thought it was one political rally.
Thank God The Nigerian Observer has been reinvigorated and renewed, they will help us push the news to the people in Edo State.
You stated that the GIFSHIP for individuals is N45,000. If a pregnant woman pays N45, 000, and eventually gives birth through a Caesarean Operation (CS), how does it cover?
When you talk about health insurance, it works on pooling; you pull resources together. All the resources are put into one pool for everybody. That is the beauty of it, for everybody to use. You contribute your N45, 000 and you put it in a pool. Maybe a man has three wives, and four children and he pays for his own, N150,000 we put in the pool. I put my own in the pool. Not all of us will fall sick at the same time.
So whenever one falls sick from the pool is taken his insurance. So pregnancy is covered. That N45,000 is not for you alone, it’s for three of you.
If you get pregnant, prenatal, antenatal, postnatal, and the child will be covered for the first three months in that N45,000. It’s not even your N45,000 that is working, it’s your N15,000 because if you are three, just N15,000 will be paid by each of you this is how the formal sector works it should be noted for the GIFSHIP you’re not qualified for any surgical operations (CS etc) until you’ve spent at least 6 months in the scheme.
We have a benefits package, which is one of the robust benefits packages. With N15,000, you can even collect glasses.
The person can even get an artificial limb if he gets involved in an accident and if it is needed under this scheme, you can have prosthetics. But the artificial limb will be made in Nigeria prosthetics. CS, surgery, appendectomy, *all* is covered.
Some insurance schemes will tell you to pay a percentage of the whole amount of whatever you are charged at the hospital. For example as a beneficiary, you are supposed to pay 10 percent, 5 percent. Can you explain how this works?
People just say when you go to the hospital the bill they give you; you are to pay 10 percent. It’s not correct.
Under the National Health Insurance Authority, when you get to the hospital, you know, there’s registration, consultation, and medication. You pay 10 percent only for medication. It doesn’t matter if they do the test.
When they give you drugs, what is the total cost of the drugs that were given to you? That’s what you pay 10 percent for, not the whole. Somebody can undergo a CS operation now in the hospital, no CS operation is less than N150,000.
The CS has a procedure, it has treatment, and drugs. All those procedures are already paid for, the drugs that will be administered during the CS, that’s what the person is going to pay the 10 percent for.
In the end, the person may just pay N4,000 for a CS operation. How does it work? We have several kinds of payment mechanisms. We have the capitation, fee for service, and per diem.
The capitation is a payment that is made to the hospital ahead on behalf of the enrollee. Whether you go to the hospital or not, we pay the money to the hospital ahead.
So because of this, they don’t have any reason to tell you OS (out of stock) because we have paid ahead. This capitation payment is for primary consultation, drugs, and the like.
Then when it comes to surgery, for the procedures and processes they are going to perform, there is another payment, NHIA will pay, which is called the *fee for service. For any service that you do, the fee will be paid to you. If you don’t do any service, that money does not come and it is especially for secondary services like surgery, optometry, O&G, and the like.
Per Diem means per day. When somebody is hospitalized, under the National Health Insurance Authority, as an enrollee, he is entitled to 21 days of cumulative hospitalization without paying in a year.
That means the person can be admitted for a maximum of 21 days within a year in a standard ward, not a private ward. After 21 days, you start paying.
Now, if three people register, your 21 days are not transferable. Each person is entitled to 21 days. If somebody goes to the hospital now, maybe was admitted for six days before discharge, that means in a year he has spent six out of the 21.
If another time there’s an admission and at the end of the year, this person spends only ten days out of the 21 days, it has expired.
If I’m an informal enrollee, do I just choose a hospital?
The good thing about this thing is you have a choice. It’s one of your responsibilities.
Whether you are in the formal sector or you are in the informal sector, you are the one to choose the hospital, we don’t choose for you, so you must have made your survey on the hospital. We also advise that the hospital you choose should be close to where you stay in case of an emergency, and we also work on a referral system. Many people want to choose UBTH (University of Benin Teaching Hospital), and Edo State Specialist Hospital. We just tell them, and if it’s close to you, good.
You can’t reside at Ogumwenyin and you go choosing UBTH. In case of emergency at night, you don’t have a car, how do you get to UBTH? Because that’s your primary provider.
But if there is a clinic close to you that provides primary healthcare, and if there is a need for referral, the hospital can refer you to any hospital, whether public or private, UBTH or Specialist. But at least your primary provider should be close to you. Not all clinics have optometrists.
You can’t say because you want to do an eye test you now go and choose UBTH for example. You can be referred from your hospital to a standalone optometrist who is registered under NHIA and you will be treated, collect your glasses, and go.
Except you are paying like, for example, your frame now can be N350,000. We don’t give those kinds of frames. The maximum we give for the frame is for glasses, and it is N10,000 for now If you take anything more than that, you pay the difference.
Then another thing you also need to know is when somebody is hospitalized. When I say hospitalization, it doesn’t mean that you will not go to a private ward. The enrollee is entitled to hospitalization in a general ward.
But if you say you don’t like the general ward, you want a private ward, you are free, but the cost will be on you. So what is the cost? What is the cost that NHIA is paying for General Ward? You need to find out from the hospital.
Then the one you are choosing, what is the cost? Work it out and pay the difference and you go for the private ward. So it is also in drugs and medication. We don’t use branded drugs.
We use generic drugs. If you go to the hospital, they give you a generic drug and you say you don’t like it, you want a branded drug, no problem. Tell the pharmacist, you pay the difference between the branded and the generic. It’s something that you can just discuss, provided you don’t bend the rule.
What’s the difference between generic and branded drugs?
The difference between generic and branded drugs is the brand. The generic drug is the constituent and what matters is the constituent.
What if someone takes a child for a checkup when you think something is wrong for example physical discoloration of the teeth?
If you think something is wrong, you go to your GP (General Practitioner) first, he’s the one to tell you to go and see a dentist.
For the service fee, before they are paid, there must be a diagnosis that was arrived at.
But if there is a clinical diagnosis, for instance, someone comes in with a bleeding gum; they will be directed to see a dentist so that they can check what is there.
Sir, we are seeing a meritorious award given to you by an organization what does this Award represent?
For this award, well, as you can see, I was sitting in my office when the Forward News Media brought the meritorious award; stating that they have been watching all NHIA Edo State has been doing, hence they decided to come from Delta State and give me the award.
The award means a lot to me and Edo State Office. It shows people appreciate what we are doing and it’s a call to do more
