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2 SOCIAL HEALTH INSURANCE Based on the concept of social solidarity A social security system that guarantees health care services to participants On payment of token contributions at regular intervals Contributions are paid into a common pool Contributions based on ability to pay Access to health care services based on need Payment for health care services made from the common pool

3 HISTORICAL PERSPECTIVE Bill for health insurance introduced in parliament in 1962 Successive govts identified with it but lacked political will to commence it Documents modified over the years to suit peculiarity of the country NHIS finally established by Act 35 of 1999 Launched 6 th June 2005 by President Olusegun Obasanjo, after 43years Access to health care by enrollees commenced in September 2005

4 WHY HEALTH INSURANCE High mortality rates -Infant MR 100 for every 1,000 live births -Maternal MR 1,000 out of every 100,000 live births 17% of women have no assistance during delivery Live expectancy at birth 47 201 out of every 1,000 children born die before they reach age five 4

5 THE NHIS NHIS is a body corporate with perpetual succession Established under Act 35, 1999, To provide social health insurance in Nigeria where health care services are paid for, From the common pool of funds contributed by the participants of the Scheme.

6 VISION A strong, dynamic and responsive National Health Insurance Scheme Totally committed to securing universal coverage and Access to adequate and affordable health care in order To improve the health status of Nigerians, especially for those participating in the various programmes/products of the Scheme.

7 MISSION To facilitate fair financing of health care costs Through pooling and judicious utilization of financial resources To provide financial risk protections and cost- burden sharing for people against high cost of health care, Through various prepayment mechanisms prior to their falling ill. This is in addition to regulatory oversight of HMOs and HCPs

8 RATIONALE FOR NHIS The general poor state of the nations health care services Dwindling funding of the health care sector Increasing the financial resources for healthcare

9 RATIONALE FOR NHIS cont Poor integration of private health facilities in the nations health care delivery system Excessive dependence on govt health facilities Private huge spending (60%) on health services as out of pocket expenses Establishing patients rights as consumers Create demand for health care services

10 OBJECTIVES OF NHIS –To ensure that every Nigerian has access to good health care services. –To protect families from the financial hardship of huge medical bills. –To limit the rise in the cost of health care services. –To ensure equitable distribution of health care costs among different income groups. - To ensure efficiency and high standards in health care delivery services

11 OBJECTIVES OF NHIS cont –T–To improve and harness private sector participation in the provision of health care services. –T–To ensure equitable distribution of healthcare facilities within the Federation. –T–To ensure equitable distribution of health care costs among different income groups –E–Ensure equitable patronage of all levels of healthcare. –T–To ensure availability of funds to the health sector

12 CORE FUNCTIONS Maintain and operate a health insurance fund. Issue guidelines, set standards and regulate activities of HCPs, HMOs and other health insurance actors Mobilize additional resources to fund the health sector. Define benefit packages and introduce health insurance products. Register HMOs and health care providers Build capacity of health insurance operators. Periodic actuarial analysis and determine capitation and other payments

13 PROGRAMMES OF NHIS Formal sector progrmme -Public sector (Federal, State, Local govts) - Armed Forces, Police and other uniformed services - Organized Private Sector - Students in Tertiary institutions - Voluntary participants

14 PROGRAMMES OF NHIS cont Informal Sector Programme - rural community - urban self employed Vulnerable groups -permanently disabled people and aged - children under five - prison inmates Others - international Travel health insurance - retirees and unemployed

15 Benefit Package Out-patient care, including necessary consumables; Prescribed drugs, pharmaceutical care as contained in the NHIS Essential Drugs List Diagnostic Test Lists; Maternity care for up to four(4) live births for every insured contributor/couple in the Formal Sector Programme;

16 Benefit Package contd Preventive care, including immunization, as it applies in the National Programme on Immunization, health education, family planning, antenatal and post-natal care; Eye examination and care, excluding the provision of spectacles and contact lenses

17 Benefit Package contd Consultation with specialists, such as physicians pediatricians, obstetricians, gynaecologists, general surgeons, orthopaedic surgeons, ENT surgeons, dental surgeons, radiologists, psychiatrists, ophthalmologists, physiotherapists, etc

18 Benefit Package contd Hospital care in a standard ward for a stay limited to cumulative 15 days per year. Thereafter, the beneficiary and/or the employer pays. A range of prostheses (limited to artificial limbs produced in Nigeria)

19 Benefit Package contd Preventive dental care and pain relief (including consultation, dental health education, amalgam filling, and simple extraction). Note: All Providers are expected to provide counseling as an integral part of quality care.

20 EXCLUSIONS Total Exclusion Occupational/industrial injuries are excluded to the extent covered under the Workmen Compensation Act. High technology investigations, except in life-threatening emergencies, e.g. C.T scan, MRI Injuries resulting from: a. Natural disasters, e.g. earthquakes, landslides, etc (force majuer) b. Conflicts, social unrest, riots, wars, etc. Domiciliary visits Periodic medical check-up unrelated to illness

21 EXCLUSIONS contd Epidemics Family planning commodities, including condoms Injuries arising from extreme sports, e.g. car racing, horse racing, polo, mountaineering, boxing, wrestling, etc. Management of drug abuse/addiction Terminal illnesses, including all Cancers

22 EXCLUSIONS contd Surgery i. Transplant and cosmetic surgeries ii. High cost surgical procedure, including organ transplants, e.g. open-heart surgery, neurosurgery (except Borehole), laminectomy etc Ophthalmology Provision of spectacles, contact lens, etc ENT Hearing aids and associated appliances

23 EXCLUSIONS contd Medicine i. Management of CVA beyond the initial treatment ii. Tuberculosis iii. Chronic renal failure Paediatrics i) Congenital abnormalities involving major/extensive surgical repairs, e.g. separation of Siamese twins, omphalocoele, etc. ii) Chronic congenital defects, e.g. Hirschsprung disease, etc.

24 EXCLUSIONS contd Obstetrics & Gynaecology Infertility management Dental i. Dentures, crowns, bridges, implants ii. Scaling and polishing iii. Maxillo-facial surgeries iv. Root-canal treatment Provision of meals on admission

25 EXCLUSIONS contd Partial Exclusions For life-saving emergency treatment requiring high technology investigations, the HMO would pay 20% of the cost, Screening: Prostate Specific Antigen (PSA), PAP smear, Mammogram: the HMO would pay 20% of the cost However, in observance of any existing contractual agreement between employer and employee, the employer may choose to undertake extra cover in addition for its employees.

26 Categories of Healthcare Professionals under the NHIS General medical practitioners Specialist medical practitioners Pharmacists Lab scientists Physiotherapists Dental surgeons Community health workers

27 General Requirements for Health Care Providers (HCPs) Possession of the relevant academic qualifications in the field of endeavour; Registration with the relevant professional body; Possession of the current license to practice; Appropriate facility for service delivery; Registration by state authorities (where necessary); Possession of malpractice insurance cover.

28 Requirements for General Medical Practitioners Possession of the Bachelor of Medicine, Bachelor of Surgery (MBBS) degree, or its equivalent, recognized by the Medical and Dental Council of Nigeria; Registration with the Medical and Dental Council of Nigeria; Possession of the current licence to practise, issued by the Medical and Dental Council of Nigeria (MDCN).

29 Specialist Medical Practitioners physicians, paediatricians, psychiatrists, surgeons,dental surgeons, ENT surgeons, radiologists, gynaecologists, ophthalmologists, etc. Requirement is possession of recognized specialist qualifications in the proposed area of practice

30 CLASSIFICATION OF HEALTH CARE PROVIDERS Primary Health Care Providers - First contact with the enrollee, i.e. gatekeepers. Primary Health Care Centers Comprehensive health care centers Nursing and maternity homes. Out-patient departments of General Hospitals, Specialty Hospitals, Specialist Hospitals, Federal Medical Centers, Teaching Hospitals, Hospitals/Clinics of Armed Forces, Police and uniformed services, University Medical centers, Federal Staff clinics/Hospitals. v) Non-specialist private hospitals and clinics.

31 Secondary Health Care Providers Secondary Health Care Providers - (Fee-for-Service Providers) – provide health services on referral from Primary Providers General hospitals (out-patient specialist care and in-patient care for medical, surgical, paediatrics, obstetrics and gynaecology etc), Specialist hospitals Federal medical centres Pharmacies Laboratories Dental clinics Physiotherapy clinics Radiography centers, etc.

32 Tertiary Health Care Providers (Fee-for-Service) Tertiary Health Care Providers (Fee-for- Service Providers) provide health services on referral from primary and secondary levels. These include :- Teaching hospitals ; Specialist hospitals, Specialty/specialized hospitals (orthopedic, psychiatric, etc), Federal medical centres, and Military reference hospitals.

33 FACILITY REQUIREMENTS FOR PRIMARY HCPs Waiting and Reception Area Consulting Room Treatment Room Patients toilet facilities with adequate water supply Sterilizer/Autoclave Emergency tray

34 FACILITY REQUIREMENTS FOR PRIMARY HCPs contd Appropriate fire fighting equipment Adequate waste disposal facilities. Containers for disposal of sharp objects Refrigerator

35 Personnel Requirements Primary Healthcare centers meet the standards set by the National Primary Health Care Development Agency (NPHCDA), Other primary HCPs should have the following: At least one medical practitioner At least two registered nurses/Midwives At least two hospital assistants At least one administrative staff for medical records and secretarial duties

36 REQUIREMENTS FOR SECONDARY and TERTIARY HCPs Out-patient and in-patient services for medical, surgical, paediatric, maternal care, etc. The minimum requirements for a tertiary hospital is as in a secondary healthcare centre, but with the additional requirement that each specialty be fully devoted to the specialty

37 ACTIONS AND PROCEDURES AT EACH LEVEL OF CARE These are listed in the Operational Guidelines Includes mental health cases at all the levels of care. Enrollees in the NHIS are entitled to hospitalization in general wards only, with the exclusion of meals. However, the use of amenity/private wards and feeding will attract extra charges to the enrollee at the point of use.

38 REFERRALS Actions and procedures at each level listed in guideline Primary HCP is first port of call for enrollee ie gate keeper Cases that require specialist attention or investigation are referred Referrals are to ensure cost-effectiveness and efficiency in patients management under the NHIS. Referral is from Primary to Secondary or Tertiary provider Approval by the HMOs is necessary, except in emergencies Notification of such emergencies should be served within 48hrs.

39 REFERRALS contd Referrals should be to the nearest accredited secondary or tertiary HCP. The condition must be covered in the benefit package Condition not covered by capitation Referral letter must accompany every case. Personal and medical details must be contained in the referral letter. All investigations carried out at a lower level must be sent to the higher level.

40 REFERRALS contd The outcome of a referral should be properly documented. Referred cases must be sent back by the specialist after completion of treatment to the referring provider, with a report and instructions for follow-up management

41 REFERRALS contd Information Required for Referral Patients name, gender, age and address Referral location (dept/clinic) Patients hospital number Patient HMO and NHIS number Referring Providers NHIS registration number Referral date Clinical findings/investigations and results Provisional diagnosis Reasons for referral Referring personnels name and signature

42 PROCEDURE FOR THE ACCREDITATION OF HCPs All health care Providers are to be accredited by the NHIS as a prerequisite for participation in the Scheme. Providers are to obtain the necessary documents stipulating the minimum requirements for accreditation. The NHIS may accredit Providers only after inspection. Accreditation fee is N10,000.00 Five Thousand Naira Renewal fee N5,000.00. The fees are subject to review.

43 PROCEDURE FOR THE ACCREDITATION OF HCPs cont Obligations of the Provider shall include: Providing the NHIS with the following information:- - i) Names of serving health professionals and their qualifications (doctors, nurses, pharmacists, etc); - ii) Work hours; - iii) Details of equipment available for medical care; - iv) Ensuring every beneficiary who visits facility is attended to with utmost care, skill and prompt attention; Adopt operational techniques that shall protect patients confidentiality.

44 OBLIGATIONS OF HCPs All accredited Health Care Providers enter into agreement with the HMOs for two years in the first instance, subject to renewal. Agreement between Provider and HMO shall include the following terms: Acceptance by the Provider to provide healthcare services, 24 hours a day and 365 days in the year; Accepting beneficiaries without discrimination; cannot reject patient except on appeal to NHIS stating grounds for rejection; this shall be only after three months of initial registration with the provider; Stock generic drugs based on the National Essential Drugs List;

45 OBLIGATIONS OF HCPs All beneficiaries shall be given adequate treatment; A Provider shall not see a beneficiary as a private patient; Sending patients only to the NHIS-accredited specialists facility; Using only the approved referral line. Either party to the agreement shall have the right to terminate the agreement by giving 3 months notice in writing from the day of receipt of notice.

46 OBLIGATIONS OF HMOs The obligations of the HMOs shall include payment of capitation for primary health care providers and fee-for-service for secondary and tertiary HCPs. The NHIS shall regulate all the fees payable. The HMOs shall: i) Ensure continuous monitoring of the Providers. ii) The Providers should allow HMOs easy access for such monitoring.

47 PAYMENT OF HCPs Capitation –550 per enrollee per month –Actuarilly determined –Paid 14 days before beginning of covered month FFS –Fee schedule/price list –Claims to be submitted monthly to HMO within 14 days –Claims for settlement by HMO within 14 days of receipt after verification –Patient makes co-payment for drugs

48 MALPRACTICE INSURANCE A professional indemnity insurance against the risk of professional malpractice a participant believes he/she has suffered injury proceeds to court to seek redress, as a result of which compensation is awarded to the participant. claims for damages, breach of professional duty, negligent act, error or omission by the HCP Insurance Company accredited by the Scheme

49 MENTAL HEALTH Mental health adequately covered as listed in Guidelines Minor psychiatric services covered at primary level Major psychiatric problems covered at secondary/tertiary level care Psychotherapeutic drugs listed in NHIS drug list



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