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Why We Took Health Insurance, Free Under-05 Scheme For Pregnant Women To Rural Areas – Delta’s Health Commission Boss



Health Insurance

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Dr. Ben Nkechika, is the pioneer Director General/Chief Executive Officer, Delta State Contributory Health Commission (DSCHC). Dr Nkechika believes all Deltans deserved to have access to quality health care as such, health care must be accessible and affordable to all. In this interview, he spoke about the success stories of the state government health insurance scheme, the free maternal care programme for under-05 and pregnant women as well as efforts been made to ensure rural dwellers gain more from this schemes.


What is the contributory health commission all about.?

The Commission was borne out of a situation in the country where the country realized that 97 percent of residents of Nigeria were paying what we call out of pocket. So, when you are sick, you go to the hospital. You pay for card, consultation, drugs, lab, and you pay for everything. So, by the time you go through that, one’s time is wasted, you have to pay cash for everything and it now turned out that a lot of people that are poor and not indigents, when they are now sick, they have two options, they either go and borrow money putting them into more poverty or they go to native medication which worsen their health or they just live life like that. It became a problem where it was noticed that if they start up a programme where there is a collective effort towards health care financing, that somewhere along the line, there will be a balancing factor. That ability also puts health on the front burner where hospitals are now properly equipped to operate and then people are now able to work into the hospitals even when they don’t have money to provide care and that is basically what they call health insurance.

Just like vehicle insurance and co. So, it was determined that there should be health security in the whole country and that is how NHIS was birthed. And after several years, they realized that NHIS at the national level was not spreading well, just remaining in the urban areas. So, in 2015, they now passed a new resolution that NHIS should decentralized to state. So, state will now setup what they call state supported health insurance programme because in that way it takes this same thing down to the grassroot. So, somewhere along the line when the current governor of Delta state, Dr. Ifeanyi Okowa, was chairman, Senate Committee on health, he was spearheading this health insurance programme and I was actually doing a course abroad and we happen to meet and had common interest. So, we started developing the policy to implement it in Delta State and as soon as he became the governor, infact while he was campaigning I was actually doing the blueprint and as soon as he became governor, the bill was ready. We presented it to him, he took it to the house of Assembly and I thought my job was over and I travelled back to Abuja and they called me back that what you have done you have to come and implement it.

That is how I found myself to getting this job done to ensure that all residents of Delta State have access to quality health care irrespective of their socio economic status and geographical location. And in it there is a form which has been provided, where all poor people, pregnant women, children under five, elderly above 65, physically and mentally challenged will be able to go to a hospital to receive care even if they don’t have money and the hospitals will be able to provide them. Now, one critical thing, the way it is done is that health care was now split into two: there is what we called demand for healthcare then supply of healthcare. So, the health insurance demands for healthcare on behalf of the populace while the ministry of health supplies healthcare service on behalf of the doctors. So, we meet at a junction where if you provide quality healthcare for the people, we pay, that is basically how we came about this whole process to correct this imbalance in access to healthcare between the rich and the poor and people living in the rural communities and people living in the urban communities. The key point is to avoid a situation where people have to pay to receive basic healthcare. Now, one critical thing is that insurance cannot take care of everything but what we did is that we design it in such a way that 50 percent of the disease burden in Delta state was properly captured. Like when we started we had meetings with Okada riders, market women, farmers, fishermen. Everybody come and tell us what is your most challenging health situation and that was how we developed what we called the benefit package. Initially when it was done, it was supposed to be N17, 000 a year per person but when we did an analysis we realized that for the average family in Delta state to pay N17, 000 for each individual was a problem so we approached the governor he now reduced it to N7, 000 but also we now find ways to cushion it, so that it is sustainable to government. That is why you see that the premium is N7, 000 but what we are providing is N17, 000 per person and surprisingly it has been adopted across the country.


At a time, the issue of civil servants paying double came up, how was it handled?

The first thing is that when we started, there is a payroll in Delta state where Biometric data was collected by Heckerbella. So, instead of going to civil servants one by one, they gave us that data. We uploaded it from day one. So, every civil servants was registered in one day but because the data they collected was employment data, health care service data is very peculiar. People would have had a wrong age, you know age is very important in the quality of medicine that they give to you. We now said that though we have collected your data but you need to come and look through what we have and confirm that what is there is correct so that when it is correct we now print your ID Card and give to you. That is the first thing we did. We also said that if more than one member of the family is earning, they will choose who will become the principal person then every other person is recorded as dependant. If you look at our ID Card, you will see DEP. It means dependant. So, there is only one principal in the family, all the others will not pay. Even in our law if the husband is contributing from NHIS, the entire family is exempted.

So, even a civil servant here that the husband is in the NHIS scheme, the wife does not need to collect that is even when you are a civil servant on the state and it is properly documented. But because we are just a beneficiary, all they do at the end of every month is that they will send us that these are the people whom they deducted money from for the month. So, we setup a system it was even sent as circular that all civil servants should write through their MDAs to head of service so that they stop their deductions from payroll because the deduction is done at payroll monthly and we have copies so when you send we have copy but you know because is manual, when they give you the list it is difficult to start checking. So when you complain officially to us, we will tell you go to head of civil service, deduct it from payroll because we cannot utter the payroll because our law is very clear, only one member of the family is deducted and even if a member of the family has a husband or a wife that is in the federal NHIS, you are exempted in Delta state, they don’t collect from you that is the standard here. So, we don’t control it, we just receive data and we just have A, B and C. So, that’s the process, but we are not involved in it, we just collect data and what is given to us at the end of every month.

Most civil servants in the state complained that when they visit hospitals, they are not attended to as expected and many at times, they are just given only paracetamol, what is your commission doing about this.?

Yes! We have received such complaints and we put in certain measures so we first of all look at our operational guidelines. There is a penalty. So, if you go to a hospital, you either don’t receive care or they don’t receive care on time, they don’t receive the appropriate drugs or does not even get treated well. First of all that hospital would be fined N200, 000, it is gazetted, the head of the hospital will be penalized. In fact, we have made it so serious that if it is a doctor, we report to Nigeria Medical and Dental Council. If it is a nurse, we report to Nurses Council. At a higher level, we can actually report to the Attorney General, the person can actually be prosecuted and the person can become an ex-convict with a fine. But the question is this, you cannot go through that level accept you have hard copy evidence. So, what we did when we noticed that initially was to put what we call suggestion boxes in every hospital so that if you have complaints, write and put it there. We realized that when we go to the suggestion boxes, somebody will break it and take them away, we now put in what we called agents, we have our agents, we call them mystery patients.


Sometimes, we send mystery patients to go and check, we have them in the hospitals walking around and we actually have reports of workers but all we can do, is write a report. We cannot prosecute because for us to be able to do that, there must be a panel setup by the supply side. The Ministry of Health has the mandate, we cannot summon a doctor or a nurse for not attending to someone. So we write to the Ministry of Health, they investigate and take action. But on our own we won’t let that continue. If you look at the back of every card, there is a number there, a 24hr number. So we told all our enrollees, if you are in a hospital and you are having challenges just dial that number. I was even the person that has that number for sometime until it became very overwhelming for me so I decided to assigned a staff and we increased the number to four, two of the phones are among that list and it is always with me. I carry it everywhere, the reason I do that is just in case anybody start calling this number that means all my other staff are not answering their own. But the problem is if we get the call, what we can do is to call the hospital.

Infact, one honourable member called me three weeks ago that he is in a hospital and they asked him to pay N3,000 and I said fine, you are an honourable member, pay and collect the evidence of the receipt, I will personally refund your money. There is also a case that we are investigating but even in the investigation we have to be careful to protect it. A woman went to a lawyer to borrow N20, 000, she said she went to a hospital to give birth and that they say she should bring N20, 000, and I said give to the woman let the woman give to the doctor and get me the information. Let him finish treatment that doctor is in trouble because we have been able to track that information but the question is how many can you trace? That is why we setup that programme where if you are having any problem at the point of care, you call but we we also try to talk to the Ministry of Health. What we now further did was that we setup the labour monitoring committee, NLC is part of it, nursing council is part of it, TUC, is part of it, NMA is part of it. All Labour union setup a committee, once we see such cases we follow it up. While we are following it up in the technical way, we are also following it up the labour way so that even when we apply sanction, labour will not jump at us that why are you doing that. All in an effort to correct that situation. It is an insurance, you are supposed to provide primary care first. So we do a lot of advocacy to educate the doctors and the nurses that look at the situation.

Infact, there is what we called the benefit package, that is pasted in every hospital because it is not all cases that are covered. Sometimes people go to the hospitals they are told this is not covered and we tell them to point at it or we tell them to call us. We tell the patient either yes, this is covered or is not covered or we tell the doctor this is covered or is not covered. But one thing we also do, any patient who comes to the hospital, whatever situation the patient has you must provide the care because we have that provision for the patient. If a woman comes to the hospital and she is in a medical condition, you won’t say because it is not covered, the woman should die, no. Provide care, we know how to handle those extras but also to prevent abuse that is why that restriction is put in place. So, yes it exist, we investigate, there are sanctions, we have penalized certain people but what will help us is educating the people, letting them know that at the back of your card, there is a number there. If you are having any problem call that number, if you are told to do this bring the evidence, we will prosecute the people, that is the best we can do but we will continue to strive on, but the most important thing is that education. Educating people that it your right. You know what people don’t understand, in the previous system, you are buying healthcare but in health insurance, you have paid upfront. So, your rights are even stronger. So, once you pay health insurance, it is a malpractice for the hospital not to be opened. If a hospital changes its address without informing us, you are sanctioned because you must remain open for the enrollees that you have received payment for. So, if you have collected somebody’s money, you must provide care, you must be available, you must treat the person on time. We are taking it to the next level, to what we call patient rights. Let the patients know their rights and let them know that you can actually make a case and succeed in it. We are empowered to act, we need information and we need supporting action.


Since the inception of Governor Ifeanyi Okowa-led administration, we no longer hear of the free Under O5 and maternal care for pregnant women put in place by the former governor, Dr Emmanuel Uduaghan-led administration, What happened.?

When we were designing the programme, infact, we were happy that such a programme was existing that there was this free under 5 and maternal. Actually that was what we started with. On 1st of January 2017, we started by following that programme. It is existing everyday but there was a difference. When we started those services were only in government hospitals that were in town and we noticed that a woman will drive an SUV, drive into a hospital and receive free treatment. Meanwhile, in the rural communities where these poor people are, it was not available. Infact, we found one situation where one taxi driver, will park at the bridge head, carry pregnant woman, cross the bridge drive into Okwe, receive free treatment, collect medical bills from them and drive them back. So, we now said the programme will continue but it will go to primary healthcare centres. Not only in the urban centres because it was only in the general hospitals. It should also go to the rural communities, so we started with 100 PHCs to add to the existing ones. The programme continued but it expanded. Two, we realized that we need the data because looking at such a beautiful programme for eight years, no records. Let say throughout that programme, there were 1000 pregnant women. How many survived? How many went through CS? What is the data? How many were children? Who followed them up? If you don’t collate that data and you know data is keen. Information is money so that was why we started to make sure that every pregnant woman that walked into the hospital, we collect your name, age, sex, LMP for both your husband and your children so that we take that family as a treatment unit as against just treating the mother. So you find a situation where the mother has come for treatment, you have treated the mother, the child has come for treatment, you have treated the child.

Meanwhile, there might be a disease condition linking the two, you won’t know. So, when we register the mother, we register both you and all the children in the family. Yes, we are providing free healthcare for the under 5 and the pregnant mother because we also watch where the family is, we tell them bring your husband. So we started collecting data. As at last records its over 6000 pregnant women and children under 5 that we have treated under this programme. We are the only state in the country that has received that award from the world bank under it you save a million lives. That Delta is the state where you have the highest number for the poor and vulnerable population. If we are not doing it we will not receive these awards. Since 2017 till date, we are still maintaining that number one position. Nobody has challenged us and what we are saying is that this information is verifiable. If you want to know how many pregnant women we have delivered, their names, pictures, you will see all there. We transitioned it. The difference is that we are now collecting data and we now spread it to primary healthcare centres. One other thing too is that when we started this health insurance scheme programme, we didn’t want it to be a political propaganda, we wanted our service to speak for us and not the jingles to speak for us. So, for the first few years, we were concentrating on building a structure and we are working hard. There is basically no community in the state that I have not been to. Why? Because we go there to check, to monitor. If you go to most of our hospitals, we have what we call community based agents. They go from house to house in every community, letting them know that every child under 5 in the community, if you go to the hospital don’t pay, if they tell you to pay call us and these people are residents of the communities.

So if a woman goes to the hospital and they tell you to pay just call them and they all have a handset. They also tell them how to live well. So, we are doing what we call house-to-house education. We had a meeting with President Generals of all communities, all the traditional rulers in Delta state, it was the same message we said they should pass on. So we have done it in several levels until we now realized that the most effective one is this house-to-house. So every day our agents post to us the number of house they visited. We are not doing the propaganda in town we are doing it in the rural communities because if you keep doing health insurance in the town, the poor people are actually in the villages, they are the people that actually need it that is why we took the service there. Like the first time I came, we couldn’t find one viable facility in the villages but today we have one in Porogbobo, for the Egbema and Oporoza for Gbaramatu kingdoms. We have setup for the Ode- Itsekiri, for the Itsekiri kingdom, we are starting Irri for the Isoko area. Why are we doing that? To make sure that healthcare services are available to people. Our strategy is that nobody should travel more than 30 mins to receive health care, it should be a walking distance for you to get healthcare services. So, we are not the publicity type, we believe that our work will speak for us.


This is a syndicated interview…To be continued next week Sunday