Hon Commissioner for Health Challenges and Opportunities for Financing Privately Provided Healthcare in Nigeria Dr Olaokun Soyinka Hon Commissioner for Health Ogun State Nigeria (2011-2015)

Outline Context – Health in Nigeria & Progress to UHC Public & private – an unhealthy dichotomy Araya – the Ogun State Community-based health insurance scheme Engaging the private sector Conclusion Three wishes

Lagos Bayelsa Rivers Imo Abia Akwa Ibom Adamawa Bauchi Gombe Kaduna Fct Nassarawa Plateau Taraba Benue Cross River Enugu Ebonyi Anam- bra Delta Edo Kogi Oyo Ogun Osun Ekiti Ondo Kwara Niger Sokoto Kebbi Zamfara Katsina Kano Yobe Jigawa Borno

Nigerian Health 900,000 Maternal and Child Deaths Every Year in Nigeria 13% of under-5 deaths & 14% of maternal deaths globally – 2nd only to India Trends in service delivery – little improvement 1990 - 2013

Universal Health Coverage Presidential Summit on UHC - 2013 “Considering the overwhelming global support and documented benefits of UHC in theory and practice, the Nigerian federal and state governments are implementing initiatives to contribute to the attainment of UHC in the country”

Initiatives Human resources – MSS scheme Financing initiatives: Free Healthcare (vulnerable groups) Health Insurance (formal sector) Community based health insurance schemes Conditional cash transfer Construction of facilities

Impact These have had limited overall impact Out of pocket expenditure still hovers around 70% Less than 7% of Nigerians are covered by any sort of prepayment scheme Quality and scope of service delivery remains poor

Impact Major inequities exist: In 2013 approximately 58 million Nigerians were living in poverty The are disparities in poverty levels with higher levels in the north compared to the south 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 quintile Disease burden is highest and access to healthcare is lowest amongst the poor

How to get to UHC Government has not had a good track record of sustained attention to health care or the ability to deliver acceptable quality Lack of political will Bureaucracy Corruption Inefficiency Poor self regulation Conflicts of interest Labour unrest

Private? Largely unregulated Often Driven by profit motive Variety of specialist practitioners of dubious quality TBA Bone setters Herbalists Faith healers There are excellent examples of private PHCs

Public/Private Dichotomy The Public and Private services are two different worlds Private sector is only partly visible to Government – data problem (= planning problem) Government is therefore failing to harness the progress in and power of the private sector and the benefits of a functioning health services market

Role of Government UHC depends of the rapid expansion of the provision of an acceptable basic level of integrated services at the primary healthcare level It is the Government's responsibility to ensure this happens but not the Government's area of strength Government should provide: Policy Regulation Enabling financial environment

Private Private sector should provide preventive, curative and other health services in the marketplace that is properly regulated by Government

Community Health Insurance in Ogun – The Araya Scheme Araya was conceived as a means of decentralising the management and financing of primary healthcare by implementing a state-supported community-based heath insurance scheme that focused on institutionalising continuous quality improvement in healthcare service provision

Araya Health insurance for the lower socio-economic groups creates many paying customers. The resultant dependable flow of finance enables the provision of integrated basic services and the potential for continuous investment in quality improvement. Araya operates as a collection of semi autonomous sub schemes, each based in a community and built around a facility. Primary care services are remunerated by paying capitation. Secondary services – fee for service.

How to get to UHC

Financing private involvement under Araya: Public Private Partnership Government facility (or facilities) given to private operator. The operator invests and brings the facility up to miminum standard. The facility becomes a provider under the Araya scheme and enrols community members. The provider is given capitation payments (fee for service for secondary services). The provider has access to soft loans to encurage rapid quality improvement.

Financing private involvement under Araya: Public Private Partnerships S/N FACILITIES LGA 1 Odo-esa PHC Ijebu-ode 2 Ososun PHC Ifo 3 Baale Ogunbayi Odeda 4 Laderin PHC Abeokuta south 5 Mowe PHC Obafemi-owode

Financing private involvement under Araya: Private Facilities A private provider applies to provide services to a community under the Araya acheme. The operator's facility is up to miminum standard. The facility becomes a provider under the Araya scheme and enrols community members. The provider is given capitation payments (fee for service for secondary services). The provider has access to soft loans to encourage rapid quality improvement. NB: Social franchising networks are in this category.

Financing private involvement under Araya: Private Facilities A private provider applies to provide services to a community under the Araya acheme. The operator's facility is up to miminum standard. The facility becomes a provider under the Araya scheme and enrols community members. The provider is given capitation payments (fee for service for secondary services). The provider has access to soft loans to encourage rapid quality improvement. NB: Social franchising and other networks are in this category.

Financing private involvement under Araya: Private Facilities Social franchising networks S/N PARTNERS NO OF FACILITIES ACTIVATED 1 MSN (social franchising) 25 FACILITIES 2 SFH (social franchising) 27 FACILITIES 3 SAFECARE (quality assurance) 7 FACILITIES (Target 60 facilities)

Financing private involvement under Araya: Private Facilities Hub and spoke networks S/N PARTNER PROPOSAL 1 Reddington To build 1 secondary facility and 4 primary health care centres in all the LGAs in the state 2 Purple 3 Utopian consult

Financing private involvement under Araya Variations on the theme PPP using a private facility donated by a charity A facility was constructed by a charity who could not afford to staff and run the PHC A private operator was found and a tripartite agreement signed between government the charitable organisation (continued low levels of support) and the private operator. The facility applied to becomes a provider under the Araya scheme and is now enrolling community members. The provider is given capitation payments (and fee for service for secondary services). The provider has access to soft loans to encourage rapid quality improvement.

Financing private involvement under Araya Variations on the theme PPP using a community facility A facility was constructed by a community who could not afford to staff and run the PHC, The PHC was abandoned for years after completion A private operator was found and a tripartite agreement signed between government the community and the operator The facility applied to becomes a provider under the Araya scheme and is enroling community members. The provider is given capitation payments (and fee for service for secondary services). The provider has access to soft loans to encourage rapid quality improvement.

Financing private involvement under Araya Community health insurance expands the health economy. By creating a means of enabling individuals to access and pay for healthcare, private providers are attracted to the scheme. Decentralisation means that experimentation with different models of collaboration can easily take place. Government's most valuable role is as a facilitator, regulator, risk pool manager and overall scheme developer.

Conclusion To get to UHC is the shortest time we must get rid of the dichotomy and break down the barriers affecting the synergy that could accelerate our progress. Sustainable finance will also accelerate the development of an efficient (well regulated) health services marketplace. Government should regulate more and implement less.

Three wishes I hope to learn: What the pitfalls to watch out for are, and lessons to be learned, from those who are ahead of us in engaging the private sector. What other models of partnership exist – and how successful they are. Whether the long term best goal is in the balance between public and private sector provision of health services.