We are building structures that will endure – Dr. Emmanuella Zamba
Lagos State Health Management Agency (LASHMA) is a body charged with the responsibility of regulating health insurance in the state and ensuring that residents of the state have access to good quality health care when they need it. In this interview with Health Insurance Today Magazine, the pioneer publication for the industry, Dr. Emmanuella Zamba, the Agency’s Permanent Secretary, shares how the agency is making efforts to realize its mandate. She also addresses sundry issues of concern to the various stakeholders in the state.
HIT: Its eight years since the establishment of LASHMA. How do describe the journey so far? Would you say the objectives have been realized?
Dr. Zamba: LASHMA is actually not eight years old. The law was established in 2015 but the agency did not start working until late 2019. We actually took off at the peak the COVID-19 pandemic, around April or May 2020. So we are still about three years at the toddler stage (laughs).
In terms of what the agency was set up to do, I think it has covered a lot of mileage. People tend to look at the success in terms of the numbers of people that you have enrolled, but it is much more than that. Number one, you are talking about something that is alien to our culture. You are talking about something that has not come out in a vacuum. Before the agency came on board on the social side, there have been private HMOs. They were providing services to the people in Corporate Lagos, so to speak. So it is like preaching to the converted. They were already under cover. The main issue is with the informal sector, which we know is a very tough nut to crack. It is not something that you can magically change overnight. It is something that you have to do intentionally and incrementally. So in terms of how much progress, I think we have done quite a bit. It is very important that if you are doing something that is going to have scale for all of Lagos, you must build structures that will endure. Structures that will not implode when it sees a little bit of pressure.
“People tend to look at success in terms of the numbers of people that you have enrolled but it is much more than that.”
What was really important, for starters, was to ensure that you have a very good foundation. You are building structures. You are agile and innovative as you go along. There is no blueprint anywhere. All of us in this social health insurance space are all new in the game. There is not anyone that will come and tell you this is the silver bullet or this is the magic path to take. You must have an open mind and be bold as well as innovative. While you are being innovative, you keep checking yourself and trying to re-direct. We have done a lot of that and there has been monumental growth, from where we were when we started, and where we are now even in terms of structuring the agency to better serve the needs of the people. That is something that we have invested quite a bit in.
“The main issue is with the informal sector, which we know is a very tough nut to crack and it is not something that you can magically change overnight”.
Let me now talk about how the agency is structured. The Lagos State Health Scheme (LSHS) law sets up the Agency, the Scheme, and the Fund. The Fund is fully functional. The Scheme comprises what we do on the social side and what private sector does. All health insurance coverage in Lagos State is under the Lagos State Health Scheme. It is a bit more than just the Social Health Insurance. I do not know if that is peculiar to Lagos but that is how the law sets us up. So there is the HMO part of us which is for the social health insurance and that is “Ilera EKO“. Then there is the regulation arm of the agency which looks at LSHS and includes “Ilera EKO” and all private plans in Lagos. Also, there is the third structure called the EKO Social Health Alliance or “EKOSHA” which has to do with resource mobilisation and coverage for the vulnerable; people who cannot pay. If you say you are doing something social, then somebody must look after those that cannot look after themselves. So how do you expand? That is really the major chunk of what the social is about, helping the helpless. So that has been set up.
We launched that last year (2022). We have made quite a lot of progress. We have partners supporting us, whether it is donor partners or even private people, politicians, a lot of support has come our way. Right now, we have more than 280,000 lives as vulnerable in that scheme. We have started the EKOSHA Community Storm where we go round the communities and we enroll. We have our computer system tool that will identify you in an objective way. Therefore, it is not that anybody can just say I am poor, please enroll me. We also have some level of profiling that we do to see how that person can be empowered because you should not just be paying for poor people. You need to have a sustainability component to help them come out of poverty so that they too can start paying. So that is the model that we are using in the Eko Social Health Alliance. For those that we have enrolled, we are collaborating with MDAs and NGOs to see who they can support in terms of skill acquisition or some level of soft loans and things like that. We do this so that over a period of time, maybe two or maximum three years, people are in a position where they can start paying in installment for them and their family. We have started that trajectory for resource mobilisation and coverage.
“The agency is not to take markets from HMO’s. What the agency is supposed to do is to increase coverage.”
With regards to regulation, I think it is only Lagos State that has any of such structure in place in terms of attempting to regulate the health insurance space. The agency is not to take markets from HMOs. What the agency is supposed to do is to increase coverage. You do what you do best (as HMOs), but do it according to certain standards. The public sector is supposed to be the protector of the masses. As long as you are not violating any rules, not over-promising and under-delivering, then you do not have any issues. Taking your clients does not help coverage and because we are regulating. We can tell you how many lives are covered under private plans in Lagos State and how many are in “Ilera Eko“.
Right now we have just hit more than 800,000 lives under “Ilera Eko” and from the HMO side, we have almost 1.9 million. So we are about 2.7 million lives covered in Lagos. We have no interest in running after those HMO lives but now, with the new law, of course, the trajectory has changed. These are the conversations that we are having with the HMOs to understand each other. We are not here to kill your business. Government cannot do everything on its own. So let us partner. These are the things we are discussing with them. So these are the mileages we have achieved with regards to regulation. You have to come and get licensed here. You must pay your Corporate Identification Number if you are a corporate body in Lagos State. As an HMO, you must have your license renewed with us. We know that you are practicing in Lagos. We know how many lives you are covering. Even if you give us your data and we see you are managing a client, we would not necessarily go after the client because we have 24 million people and counting in Lagos. So chasing your clients, for me, is a distraction. The main thing is the virgin land that has not been covered at all.
With regards to the HMO side, which is “Ilera Eko“, it is fully structured and is fully independent. We have tried to structure the arms in a way that it is separate with different staffing and there, no mingling of roles or responsibilities. Regulations know they are to regulate “Ilera Eko” as well as private plan. They are not very popular here because we are policing them. With the HMOs we have an IT platform, end to end. We are working with some HMOs and some Third Party Administrators (TPAs) that provide some level of marketing services. For us, we have independent agents and we have grown our workforce to about 60-70 people. We also have a field force of about 200 covering grounds in Lagos. I think the challenge is publicity, public awareness and social marketing because you are trying to preach to people that do not sign up. Most people will not come your way because health is not a priority for them. Most times, people that you see are may be people that are having sick children or their wives are of a reproductive age so they are looking for how they would not pay for delivery. Those are the easy converts. Surprisingly, the average informal sector person is very healthy. They are into “agbo” (herbs) and all this kind of stuff and for this, we are actually trying to see how we can work with the traditional medicine people.
“We have just hit 800,000-plus lives under “Ilera Eko” and from the HMO side we have almost 1.9million, so we are about 2.7million lives covered in Lagos.”
We have, therefore, done quite a lot in terms of setting up structures that would endure. However, we are assessing our preparedness for scale up now that the law says everybody must have social health insurance, which is “Ilera Eko” in Lagos State. We want to see that we in a position where we can scale up rapidly without collapsing. So we are building that structure systematically which has given us an advantage and we know is the sky is the limit for us.
HIT: Let us look at all that has happened in the last four years of your operations. Which ones would you call milestones that when you look back you are able to say this is when we hit it?
Dr. Zamba: So we onboarded our public servants in July 2020. That would be a major milestone although we are still at it. Early this year, we started additional benefits for public servants and we now have an inter-border cover in relationship with Ogun State whereby our public servants living in that state can access care in Ogun State. We are working with the Ogun State Health Insurance Agency on that. They have empanelled our enrollees for which we pay them premiums. We have also increased the medical benefits based on feedback from civil servants e.g. they can have MRI, CT scans, etc.
“We want to see that we in a position where we can scale up rapidly without collapsing…”
Another milestone was to expand into the grassroots. You cannot sit in your office and expect that you will cover Lagos. So we opened five divisional offices and now we have scaled-up to additional 13 sub-divisional offices. We have about 17 point-of-sale kiosks spread across Lagos so that we can spread into the grassroots. The other one is that we launched what we called the “Diaspora Plan”. That plan is opened to people living abroad to pay for their relations or families who live in Lagos. You may just want to give back and you say LASHMA, take N5million and go help me enroll some widows or some individuals. We have a lot of Lagos residents with relatives that are living abroad.
Also, we have deployed our customer app which I feel is a milestone, too. Hitherto, people would inundate our staff with queries but with the customer app, you are able to do a lot of the things yourself without recourse to us. Also, now we have a USSD Code that you can use to pay for informal sector largely. We have QR Codes that you can scan and make your payments. Of course, you can always do that on the ICT platform as well. These are ways we improving customer experience.
Another innovation or milestone is our customer service department that we started. Right now, we have 15 or 16 full time staff in there. We have a CRM platform with 24 hours service. Anytime you call, there will be someone to pick your call. We have even gone a step further to launch what we call the Service Charter, which is trying to work towards ensuring that people get satisfaction with our services.
Yet another milestone is our EKOSHA and Regulation that we started. I can go on and on.
HIT: In terms of resource mobilisation and deployment, how have the factors of the high population and high concentration of elites in Lagos helped? What supports do you from state government?
Dr. Zamba: Yes, you must give credit to the political will. The Governor has been very supportive of us. It was something that he campaigned on and he remains very consistent in achieving universal health coverage for Lagos State. In fact, he just issued an Executive Order for us to domesticate the NHIA Act and implement it in Lagos State. I would say that being amongst elites and having a huge population is a double-edge sword. Why do I say that? Where there is a vacuum, it is easy for you to fill it as you have less resistance.
However, if you are doing it in a space where you have something that is already in existence and people are enlightened and feel entitled, you know it is a little bit harder for you. You have to prove yourself, unlike somewhere else where there is nothing, so everybody is looking at you. I know that when LASHMA first started, HMOs did not really take us seriously. They were like, “it is government, they would soon be tired”. But I do believe that now LASHMA has proven itself to be an entity that you must pay attention to and that it is here to stay. It has not been an easy journey. Those factors are a blessing but you know the disadvantage is when you hear people talking about percentage coverage. Percentage coverage of 24 million people is a lot compared to percentage coverage for states that have just about four million people. There is a vast difference. So if a state is saying “I have 50% coverage”, what are those numbers compared to 10% or 20% in Lagos?
HIT: Still talking about implementation, some of the issues with implementation have to do with payroll deduction, government matching workers deduction, regular release of equity grants, and actuarial costing of premiums. How are you able to address these concerns?
Dr. Zamba: As I said, political goodwill has been very positive. Even before the previous governor, the conversation had started with the public servants as to what was coming and how we will go about it. An understanding was reached which has continued and government, because it is committed, has not reneged on paying its own contributions for public servants. That is why that has worked. We have even been able to step it up a little higher. With regards to actuarial costing, we actually had one done in 2021; when we reviewed our benefit package and based on the findings, we were able to add additional benefits to the Standard Plan. What we have now is like a revised Standard Plan. Hitherto, we did not have eye glasses covered. So you could not get glasses. But now, you can. We did not have dental extraction covered but now we have added that one. We have increased the number of specialist consultations from one to four. We quite systematically added a lot of benefits based on the outcome of our actuarial review and the articulated needs of the people. If you have a standard plan, it should cover as much as possible what people need. So in response to that, the actuarial study was done and we have now revised our standard plan to what it is now. That is a continuous exercise. We are hoping to do that next year because we gave ourselves a period of three years to look at it again. It has been institutionalised.
“…The relationship with the providers has improved and we are working on incentivizing quality service.”
As a matter of fact, we have an in-house actuary that works with us and is on our payroll. When there was an issue between the providers and HMOs, we loaned our actuary to the meeting to have a conversation with them on how they could work out the issues with the providers. And because we have this in-house resource person that is why we were able to come with some of the plans that I have mentioned earlier – Diaspora Plan, Standard-Plus, Schools Plan (whether it is primary or tertiary). We even have Telemedicine Plan for Lagos residents. These are the things that having such an in-house resource help you to look at: to calculate and hedge your risks. With this, you are able to better serve the public.
HIT: The new NHIA Act has made enrolment mandatory across the country. How has this impacted enrolment in Lagos State?
Dr. Zamba: I would say that the impact is still to be seen because you have to have a stage for planning, how you would leverage this new law to amplify what you are doing in the state. As I mentioned, Mr. Governor has signed an Executive Order that will help us to scale up in the way we should bring on board the stakeholders. We have drawn up a road map. Once we set all that in place, we are starting to implement massive public awareness and social marketing to try to get people to enroll. However, immediately the law came into effect, we changed the messaging of our sales team for the demand side in line with the mandatory nature of the law. I believe that it helped a lot especially with the vulnerable coverage because it gingered the people more. So that is the immediate impact but very shortly I believe that you will see more.
HIT: In terms of capacity to manage the anticipated volume, how ready is LASHMA?
Dr. Zamba: LASHMA is ready. For starters, we have a very agile ICT platform so enrollee onboarding and getting providers to work with is not an issue. That is because if you do not leverage digital technology, it could slow you down a bit. That has given us wings to fly, so to speak. Our people go to the field and we can register as many as 500 or 1,000 enrollees in a day. For instance, earlier this year, we had one of our donors who wanted to enroll (I think) 1,300 lives in each of 13 local governments in the state on the same day and LASHMA did it!
“LASHMA has proven itself to be an entity that you must pay attention to and that is here to stay.”
So I keep saying you have to be agile, you have to be proactive. One of the challenges I will speak to is with regards to the supply side (healthcare provision). You can only have so many facilities and a lot of it, probably, is in understanding each other that insurance is a game of volume. If you play your cards right, yes you will get the volume. It is not about looking at profit margin per person but about economy of scale. So the relationship with the providers has improved and we are working on incentivising quality service. We have categorised our providers now based on some criteria. You could get slightly higher compensation depending on your grade or level. We are trying to sensitise them to come onboard the platform. Our quality assurance team will assess you and you can easily be empanelled and start receiving enrollees. We have partnership with Safe Care that will help you to improve quality. We have set all these structures in place that when you come in, it is almost like an autopilot. We can also have provider-led enrollment whereby the provider-facility can go into the community and we support with our enrollment officers. The facility can, maybe, do some blood pressure checks and then you can use that to pull all the people in that catchment area into the hospital.
HIT: At the Health Care Providers Association of Nigeria (HCPAN) Mid-Year Meeting held in June this year, your agency made a presentation on this issue of performance-based categorisation and incentivisation to the providers. Feedback from the providers indicates that they may not really be impressed with this initiative. What is the onboarding rate currently and how are you engaging with them to get them to accept this initiative?
Dr. Zamba: I will say that we jumped from having 262 to about 369 healthcare providers just in a space of may be three months. That is 100-plus providers that came on board and they are still enlisting. After the HCPAN event, we have actually been sent the database of providers for us to see how we can work with them.
“We are not a threat as there is nothing to be gained from asking HMO’s to shut down.”
I think the space is wide enough for everyone. Everybody has a stake because 24 million people cannot all enter one facility. So as we are engaging, we are listening. This government is not about “take it and don’t leave it”. That is not the mentality of Lagos State. You have to hear all that they have to say and take it on board. We know that providers are critical stakeholders and they have their own perspectives. So we listen and if there are things that we can do better, we go ahead and do that. The working relationship has been much seamless and we have seen a lot more interests and uptake from the providers. We are even trying to work with the different categories, not just doctors; but also nursing homes. For instance, we have empanelled about five or six of them and we are getting more applications from them every day we go to inspect and we put them into the scheme. We also have diagnostic centres working with us that are already empanelled. So also dental clinics, eye clinics and recently, we just started conversation with the community pharmacists to see how we can also incorporate them. If this scheme is mandatory, it therefore means everybody has a role to play.
HIT: It has been said that many of the over 350 primary health centres in Lagos are in a poor state. With the expected increase in enrollee number in the state, how are you ensuring that enrollees have access to care in those centres?
Dr. Zamba: I will start by saying that the immediate past Commissioner for Health (Prof. Akin Abayomi) was very passionate about revitalising the PHCs. We have the Permanent Secretary on board that shares that passion. I know that there is a lot going on in terms of infrastructure upgrade and human resource improvement. With regards to our own engagement with them, it became even closer when the Basic Health Care Provision Fund (BHCPF) came on board.
“Everybody has a stake because 24million people cannot all enter one facility so as we are engaging, we are listening.”
The BHCPF says that it must be PHCs or nothing at all. Well, you have privates facilities but PHCs have first right. So that has made that relationship even closer. Although we had some of them on “Ilera Eko” before we started this, now we have a lot more based on BHCPF and it is a partnership. Right now, my officers are on the field from the quality assurance team conducting inspection of the PHCs and after that inspection, we will call a meeting between PHC Board and LASHMA where we will review the results and come up with what the issues are and how to address them. This is done every quarter and we have quality officers who randomly visit the PHCs for clinical audit. That is apart from the quarterly quality assurance. As I said earlier, we have a customer service department where any and all issues that come up with PHCs are sent to the PHC Board. So the relationship is there and I believe they are also very happy. I believe one of their issues was funding and for the fact that they have guaranteed income, they are very eager to work in this space with us. I see from where we started and now. We actually started the BHCPF I think in September or October last year. I can see the difference and it can only even get better.
HIT: HMOs are critical stakeholders in this scheme and they have complained about some of your policies particularly the requirement for them to remit 30% of their private scheme premium to the agency. How are you resolving this issue with them?
Dr. Zamba: I think when the law first came out, we had the first engagement with the HMOs on the need to quickly latch onto the law and see how we can collaborate better. The conversation at the time was about what should be our entitlement, which is remitting a percentage of the premium of ₦8,500 to us while they retain the care of their clientele and everybody is happy. You remit a portion of that to us so that we are able to provide a more enabling environment. By that I mean you contribute your own quota in terms of vulnerable coverage. Part of that money would go in that direction and part would go into regulation, (creation of) public awareness, etc. So it is a win-win for everyone. You get to keep your clientele and we are able to propagate this which would also mean more business for you. But I think maybe the understanding was not there. Maybe we were not communicating properly.
“…Mr. Governor, as I said, always has a listening ear. We are not in this to make the state fail but to make it succeed…”
Then, there is this issue of progressive financing, which was a recommendation that was made with the then honourable commissioner. I will just like to say that we hear them and that we are partners in progress. We are not here to cripple business. LASHMA is not set up to provide care for everybody. Even NHS (of UK) is wobbling, so to speak. Therefore, we hear what they have said but the truth of the matter is that we cannot run away from the law. That law must be implemented. What we are saying is that let us find a way to ensure that we fulfill the tenets of that law. So that conversation is ongoing with the HMOs currently and I believe that it will be resolved very shortly. We are not a threat as there is nothing to gain from asking HMOs to shut down.
HIT: That is quite reassuring. Let us talk about capitation payment to healthcare providers under the Lagos State scheme. There have been complaints from the providers that the capitation rate is too low. They cite the rising costs of medical inputs and services, as reasons. Does your agency have any plans to review capitation upward any time soon?
Dr. Zamba: I will say yes, we do have plans but you know it is beyond Dr. Zamba’s table. Yes, we are fully aware of all the challenges and Mr. Governor, as I said, always has a listening ear. We are not in this to make the state fail but to make it succeed. So yes, that is something that we have to take to him. However, you want us to increase capitation and also to bear the burden of getting people to pay higher premium. It would be a shared responsibility. I hope they understand that if we are championing some level of increment, they need to support the agency to get people to pay increased premium because somebody has to pay it. That understanding has to be there. You want us to do this, what are you also bringing to the table? We are in this thing together. You know if we increase premiums, it is to your advantage because frankly, as strategic purchasers it is of no advantage to us. But it is to your direct advantage. What are you going to do to add value, to ensure that people understand and are ready to pay that increased premium?
HIT: We know that Mr. Governor is very passionate about the welfare and wellbeing of the good people of Lagos State. In specific terms, what should Lagosians look forward to in this second term of Mr. Governor?
Dr. Zamba: With regards to health insurance, we just had a briefing with Mr. Governor two weeks ago where he called the health sector. I think we were the first agency, I mean the MDA, that he called in the health sector because of the importance he places on health. We talked about how far we have done and what we need to look forward to. As I said, he has signed an Executive Order which is to help us move towards Universal Health Coverage. All public service interfacing agencies, all of us are going to work together to try and bring this cause to fruition. He has actually also given his blessing to making the release of the equity fund for BHCPF more regular so that we are able to cover even more vulnerable lives than we were able to in the last dispensation. He is also very big on social protection so that sustainability component is something that will be very instrumental to us here. We are actually held the first Lagos State Health Insurance Summit by the end of July where all stakeholders in the health insurance space in Lagos came to jaw-jaw. Mr. Governor has promised to be there to listen to people. We are all in it together as we advance the domestication of the NHIA Act. He has not derailed or moved away from his position that the UHC is actually the way to go. There are great plans to revitalise the primary health centres and even the secondary health facilities. So most definitely, we will see even more good things in his next four years.
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