Introducing ICT platform to boost universal coverage
Dr. Ben Nkechika is the Director General and Chief Executive Officer (CEO) of the Delta State Contributory Health Commission (DSCHC). Nkechika, in this interview with The Guardian, said among other things that with the domestication and adaptation of an Information Communication Technology (ICT) the commission plans to reach over one million enrollees in the state by 2030 by enhancing the Delta State Contributory Health Scheme (DSCHS) and the Basic Health Care Provision Fund (BHCPF). CHUKWUMA MUANYA writes. Excerpts:
Introducing ICT platform to enhance integration
When we started our DSCHC programme because of the laborious paperwork requirement, we felt if we have to be efficient and effective, we have to deploy a complete ICT system. There was however an initial ICT challenge at the Primary Health Care Centre (PHCs) level so we started with manual and gradually transited into the electronic system. We felt that there should be a database of enrollees that you can call up immediately and that was why we developed the electronic medical records for that.
We also now have a situation in some PHCs where there are no doctors and nurses but Community Health Extension Workers (CHEWs) and we found out that most of these CHEWs don’t have the requisite skills to provide a certain level of care. So we developed a treatment protocol that is based on the National Primary Health Care Development Agency (NPHCDA) treatment guideline so that even if it is a CHEW that is in the PHC and a patient walks in and says, ‘I have example a fever,’ if the CHEW types in the fever in the App, it will show a dropbox that will guide the CHEW to ask more questions. These questions will guide the CHEW towards a diagnosis. If it comes to the typical diagnoses of example malaria the App will also suggest to the CHEW on the type of laboratory test to do to confirm if it is malaria. That gives you a complete encounter data. If the result confirms it is malaria the App will help the CHEW with treatment options and the App will also help to calculate the cost of the treatment service. So at the end of the month, it will send a message to the Scheme on how many patients are seen in a month and the kind of diseases they presented and the cost of treating them.
Because we do not want technology to be a barrier it will run side by side with the manual process for now. For the proof of this concept, we have piloted it in some PHCs and in three secondary health care facilities and it was successful. Two critical challenges we saw are the ICT capacity of the people and poor power supply at the PHC level. For power, we have put solar in all the PHCs so that they can charge the system.
In terms of the ICT capacity, we found that they were just scared of a classy desktop because we brought in a customized desktop that can actually use dual solar power and regular power supply and it runs on android systems. So the desktop is like your android phone and all the applications are there. So when we found out that the classy desktop was too elaborate for the PHCs, we now put the software in a miniature version in handheld android devices for the PHCs and the Secondary referral centers will now have the desktops.
Target of one million enrollees by 2030
We achieved 500,000 under two years because we have low hanging fruits. There was already a Maternal Neonatal and Child Health (MNCH) programme in Delta state so we just transitioned it. So what basically happened was that it was a free health care programme running in the cities. What we now did is to take it to the PHCs. We also had civil servants on the DSCHC programme. So most of our enrollees are from the formal sector and the equity group. So we do not think that we can get 500,000 from the informal sector in two years. One instructive thing is that in Rwanda the system was mandatory for every member of the family. But in Delta you cannot enforce a mandatory programme. People now register individually.
We have liaison officer who goes from house to house to educate the people on the benefits. Another factor is that most of the time people do not go to the government hospital so we are trying to renovate the 300 PHCs and make them up to date. We are training the personnel; make sure that there is a doctor and nurse presence in all the PHCs. We are not saying that because we got 550,000 in two years in one year we will get 500,000. We just set a realistic target based on what we are seeing. But if we can integrate the BHCPF with the DSCHC we can meet the target in six months. All we need is a go ahead to effect the integration.
Integrating BHCPF and DSCHS
Yes and no. We have succeeded in getting the BHCPF flagged off in Delta state and we are happy about that achievement. We are now in discussion with the Federal Ministry of Health (FMoH) on the best strategy to integrate the BHCPF with the DSCHS to improve our coverage, enhance the PHCs service delivery capacity and enhance a viable and sustainable healthcare insurance program in rural communities.
Luckily the meeting with the NHIS after the flag off ceremony has helped enhance the integration because I will give you an instant, when we got information that the BHCPF is going to be implemented, the first letter we got from the National Health Insurance Scheme (NHIS) was to our Governor, telling him to implement a health insurance scheme in Delta State as a minimum requirement. Thus Delta state was lucky to have been operating our health insurance scheme for two years now. This gives us the advantage to fast track our implementation of the program in Delta state.
What we are saying is that there has to be that handshake of a unified system as against the assumed fragmented system. So when we got that BHCPF notification, there was also notification from NPHCDA to the state PHCDA. But the flow from the NHIS part was initially not very smooth due to the challenges at the national level, which was why the acting executive secretary of NHIS was here at our office after the Flag Off to harmonize the information flow and the integration strategy. That was what we resolved that day.
Alleged duplication of functions by DSCHC and BHCPF
It is the same thing but the only difference is the benefit package. For example, lets say the DSCHS benefit package has 10 items and the BHCPF benefit package has three items, so it could mean that one to three in the total benefit package is covered free from the federal and four to ten is covered by the State. So what we are saying is that this kind of integration will provide covers for at least 70 per cent of the cases you see in the hospital. So if you make the three free for people, those not be willing to pay the Premium because the package from BHCPF is free will now see the benefit and the premium could be reduced from the initial state amount or the benefit package of the state could be increased to cover more services.
What we are suggesting for Delta State is this, once you register for the BHCPF programme, you are automatically registered for the DSCHS programme. The only reason we can do that is because we have an existing health insurance programme. So anybody that comes to a facility to receive free health care under the BHCPF programme, is automatically registered into the state health insurance programme and encouraged to top up to benefit from the extras in the State Scheme.
What we are suggesting now is because of our technical capacity discussion with the FMoH, which we are expecting they will accept. We came up with this proposal to them and the discussing is ongoing.
Does that mean the BHCPF is a threat to the state’s health insurance programme?
Potentially yes if proper information is not sent out to states health insurance systems on the integration possibilities.Our benefits package covers surgeries, psychiatry, Caesarean Section (CS), blood transfusion. Our benefit health package is not quite different from NHIS. It is quite elaborate. Cancer and kidney problems are not covered but the investigation is covered. What we are looking at is that our programme is not structured to handle complicated cases but to handle more of prevention and early detection. We believe that if you take care of that, the financial requirement to manage heavy cases will be greatly reduced.
How are you going to integrate it into the BHCPF?
That is why we decided that before we start, that we must have an ICT system in place at all PHCs and referral facilities because ICT can now differentiate the various packages. We also have an effective Drug Revolving Fund (DRF) system to ensure that drugs revolve around the PHC centres in good quality and at the right prices. We are partnering with Pharma service providers like Sanofi and Servier through our DRF programme.
The DRF is a central store where all the drug producers send drugs. They confirm quality and distribute to the PHCs who utilize it to provide care and pay DRF for drugs utilised. The drug is free to the patient but the DSCHC pays for it through service payment to the PHCs. So that is why we insisted that the money is paid to the health care facility and the facility pays for the dug it has collected from the DRF.
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