The Anambra State Health Insurance Scheme was launched on the 14th September, 2018, after the law establishing it enactment was passed in 2016. Its’ mandate is to provide quality and affordable healthcare to Anambra State citizens. Executive Secretary of the Anambra State Health Insurance Agency (ASHIA), Dr. Simeon Onyemaechi, says the government committed NGN 200 million as a take-off grant for the agency, and allowed him to set up an electronic platform to manage the entire system.
“We sourced for software developers who could provide an IT solution for the kind of system we wanted to set up,” he said, adding that the company they chose embedded their staff at the agency for six months in order to build the capacity of the team. The reason for this was simple. “We’ve always had our eyes on sustainability from the get go,” he said.
Building the right capacity was important to him. “Our staff was pooled from different ministries, departments and agencies, and we didn’t have the required technical capacity at the beginning,” he said. “We looked outside to get people from Health Maintenance Organisations (HMOs) to come and add value to what we were doing here. In addition, His Excellency the Governor approved outside recruitment in the form of two Executive Assistants who have experience across the six departments of the Agency.”
The departments are Administration and Human Resources, Accounts and Audits, Business Development and Marketing, ICT and Public Relations, and Medical Services and Quality Assurance. These departments were mandated by law and put in place to ensure that the Agency is able to run effectively, Onyemaechi said.
The Big Goal: Achieve UHC in Anambra by 2030
Onyemaechi said that only 2.4% of Anambra residents were covered by health insurance before the launch of the ASHIA scheme. “The percentage of out of pocket health expenditure is 91.9%. If you must get to UHC, there must be a basic benefit package of health services that the citizens should have access to wherever they reside,” he said. He said health insurance is a critical means by which to get Anambra to the goal of Universal Health Coverage, adding that the plan is to increase coverage in the state to 30% by 2022, then 10% every year until the state achieves 90% by 2030. “It’s easier to move from ground zero to 30 than moving from 30 to 90 percent, but that’s a universal goal and we have aligned our state to that,” he said.
The state did a synthesis on other benefit packages and actuarial studies to come up with its own benefit package cost, which was eventually pegged at N12,000 per year. The benefit package cuts across health promotion, prevention and curative services. “We added screening for tuberculosis as a stop gap for when funding from global funders stop,” Onyeamaechi said, adding that the benefit package also includes family planning, immunisation, nutrition, antenatal care and minor surgeries.
A basic package of services cannot cover everything, and Onyemaechi said the agency recognized that. “For services we do not cover, we work to purchase on behalf of our enrollees,” he said. “For instance, we don’t cover hysterectomy, the removal of the womb. If there is an enrollee of mine that requires it, I don’t tell you I don’t cover it. Whereas most gynaecologists may charge 500k to do it, using our tariff, we can negotiate on behalf of the client, and the enrollee gets the procedure for a reduced amount.” He noted that there are over 260 accredited public and private hospitals providing services under the scheme, and said the agency hopes to expand its benefit packages in the future to include services that are currently partially or completely excluded.
An innovative enrollment model
Like every other state which has launched its state insurance scheme, the big task is getting people enrolled into the pool so that they can begin to access services. ASHIA developed jingles in English and Igbo language to increase awareness about the scheme. These jingles play on both traditional and social media channels. The also organise road shows to share information about the scheme. “You can walk into any bank in Nigeria to pay for the scheme, and we have opened offices in all 21 LGAs to decentralise the registration of lives,” Onyemaechi said.
In addition to traditional means, Onyemaechi said the agency piggybacked on a cultural concept to bring more “lives” into the health insurance scheme — the art of philanthropy.
“Recognising that we live in a state where philanthropy abounds, and many acts of philanthropy extend to the people back home, we saw this as an opportunity to get people enrolled into the ASHIA Scheme,” he said. The agency paid advocacy visits to gate keepers of communities in the state to get their buy-in to the Scheme. Once that is done, they engage with philanthropists to get them to pay premiums for indigent members of the community.
Onyemaechi calls this the adoption model, where well-to-do individuals of a community pay for one year of health insurance coverage for a specified number of people, and send the funds to ASHIA. The people enrolled then access the basic package of health services for the year.
He said the Scheme currently has enrolled over 80,000 lives. Of that number, about 30,000 have come in through the adoption model, he said. In January, the agency received its largest contribution since the adoption model began, when Sir Daniel Chukwudozie, Chief Executive Officer of The Dozzy Group, which runs the Dozzy Foundation, enrolled 1,500 members of his hometown, Okija, on the scheme, which brings a total of N18,750,000 into the funding pool, Onyemaechi said.
A model to encourage willingness
Besides ensuring that indigent members of the community will be covered by health insurance, he says this approach is helping the state overcome one of the major challenges that have faced providing health insurance in Anambra State, and clearly many other states in the country — the willingness to pay for health insurance.
“Our aim is to overcome the issue around willingness to pay,” Onyemaechi said, adding, “The GDP of Anambra is N688,000 per capita income. It is higher than the national average, which is at N542,000. We have the ability to pay for health insurance but are not willing to pay.” He said the adoption model gives enrollees an opportunity to get on the scheme for a year and see how it works. The goal is that once they have enjoyed the services of the scheme for a year, re-enrolling into it the next year willingly, will come easy.
The agency got a chance to test this theory in January when subscriptions for the scheme expired. “Those whose subscriptions expired in January, I can tell you that over 80% have renewed their subscription by themselves,” Onyemaechi said.
You face disappointments, but you keep going…
For every win, there is bound to be a challenge, and for Onyemaechi, he says he recognises that charity in itself is not sustainable as a funding means for health insurance cover. To help mitigate this, he says that political will is paramount. “The zeal and commitment of a supportive governor will help, and His Excellency has shown incredible support for what we are trying to do,” he said.
Another challenge the model faces is the ever-shifting priorities of politics. “When you go to talk to politicians, their priorities may not be the same as yours, and you have to go over and over to appeal to their conscience; you face a lot of disappointment but you keep going,” Onyemaechi said, adding that, “Some politicians feel that health is not something they will use to win elections, but of the 11 politicians who enrolled people into our scheme, nine of them won their elections. You cannot overstate what this will do.”
Despite the challenges, Onyemaechi is confident that the adoption model is working to increase health cover and the scheme is here to stay. “ASHIA will have more impact,” he said, adding, “We are closer to the people. We go to the interior villages to reach the people. This is our own, and we see it that way. It is ours.”
Big plans with sure steps
The Agency held a townhall meeting with providers and enrollees to mark World UHC Day in December 12, 2019. Onyemaechi said the outcomes of the meeting showed the Agency that the majority of enrollees were pleased with the services.
Next on the agenda for the Agency includes conducting its own actuarial studies this year, with the support of partners such as the European Union/World Health Organisation, Onyemaechi said. He adds that the Agency also plans to “continue marketing the scheme using targeted private sessions with high net worth and philanthropic individuals.”
And his target for 2020 is ambitious. “Our target is to end the year with at least 500k enrollees in our scheme. It is a tall order but we will do our best,” he said, adding that once the Agency has the evidence from the actuarial studies, they then hope to use that to expand the Scheme’s benefit package.
These are important steps in the right direction to drive Anambra towards meeting its goal of UHC by 2030.
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