Health Insurance, Activism & Urgent Change


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AR: Dr Soyinka, it’s wonderful to see you again.It has been quite some time since we were on
a podium together. I am extremely pleased that you have turned your sights to activism. There are a number of things that came out of your session today, that I would love to dwell a little bit more on. One of them is to do with your sense of frustration at the death of a mother and a child, and as you said, the perpetual bereavement of a family, including young children, now left motherless. Can you just take us through that again and how it fired up your angry self?

OS: Yes, yes …you summarized it very well. It brought to head, a lot of things that were frustrating me at the time, one of these was the fact that if you are a commissioner, you are supposed to be a boss seated on top of a bunch of people who you assume are going to be operating or working in the best interest of the patient most times and within reason, but you find that there is a surprising amount of poor behaviour ranging from, maybe, mild misdemeanours to downright criminal negligence and because you are sitting on top of the system you see it live and direct ….and not just because you go to the hospitals or people getting report for disciplinary action.

You see patients writing petitions or people coming in to make an appointment to see you just to report an experience to you and of course there are people who will somehow get hold of your card; and oh yes my number was
on the website which is as it should be, so people who are tech savvy enough got hold of it and they either phone or send a text; so you can begin to get a feeling of the scale of unacceptable practice.

I think we like to think of it as yes, there are some exceptional bad apples; but generally speaking, I don’t know how to get it across to people that NO, we are in an emergency situation, the scale is massive and what we
hear about is just the tip of the iceberg! What we have come to accept as normal is actually abnormal, and that is why I began to get frustrated. You can’t shake people out of it. I used an example to show that it was quite
normal for a delegation of colleagues of the doctor concerned to feel it was fine to attempt to pressurize me not to take action because it would spoil his career and possibly damage his future.

AR: That’s the part I don’t understand, you called it a culture of collegiate culpability….or..?

OS: Culture of collegiate concern! So they were more concerned about their colleague than the harm that he had perpetrated. I kept having to remind myself that look, this guy might as well have taken a weapon and shot the woman concerned, because what happened was total negligence! What compounded my frustration was the realisation that no matter how much one blamed the individual involved, the system within which he was working was rotten. It had been flawed from medical school and upwards, and when I came to this realisation, I felt…apart from humbled and ashamed, I felt a sense of impotence because here I was in the top office in the state one looks at the problem on that scale, and realise, fine…I could go punish him,I could make sure he faced the music, but what have I done to stop it happening again?Nothing! In fact, as we were disciplining him,the same things would have been happening
over and over again elsewhere. The real underlying issue goes back to one of the main themes of this conference, which is that government is not putting enough money into healthcare.

AR: If I could put a magic wand in your hand,when you wave it, what would happen?

OS: Health Insurance! Mandatory health insurance. I have to qualify that because the word health insurance does not in itself,encapsulate what we are really talking about when we talk about managing health insurance because it achieves with one goal the solution to 100s of things that are wrong with the system, many of which I discovered after I started trying to implement the health insurance scheme in Ogun State.

It basically does what the health system is crying out for, it re-engineers it. You’ve probably been hearing the buzz words “Health System Strengthening” for decades. If I ask you what it is, you probably would give your answer and I give mine and both of us would be equally correct, but what I, …or the international partners and donors that brought that phrase in, is “…sort your system out!”. It is a mess and if we take a look at it, the only thing that can be done is to re-engineer it!

Implementing health insurance helps by the magic of money, to create that re-engineering because as you implement it you have to put things in place to manage the money. But also,what it immediately does is to turn the
disbursement or flow of money completely the other way round. Right now, the direction is top down. So you sit, you plan, you prepare a budget line, you beg the chief executive, some of it comes out and some doesn’t. And then
when it does, it takes another year before they look at it again.

With health insurance, the money follows the individual. Where the immediate need is, the money goes – because the patient is the insured party! The other thing that comes along with this is quality systems because when you
are starting a health insurance system, you have to bring people, providers and resources on board. Everyone is stepping into the same health insurance environment and will have to meet a certain set of standards. This will
obviously not be a static standard, but a continuous quality improvement standard.

So all of a sudden, there is another systemic change. Both are very revolutionary. Right now,you sort of look at the primary health centre and you say ha …it is terrible! …refurbish it! – forgetting we “refurbished” it only 10 years before! With health insurance, on the other hand, you can do that because it brings in competition. It breaks down the barriers between private health care and public health care.

One of the speakers mentioned strategic purchasing. The government now have to look at – “what are the services that I need to provide and who do I buy them from?”. “How do I ensure that when I give them my money, they will spend it right?”

Also, health insurance comes with a whole lot of IT, administration systems, management systems, etc. This means you are basically saying “…I have got this money and I’m sending it out”. What is the money doing?

What are they doing for that money? You know where it’s gone. You know what you are supposed to get for your money. Immediately therefore, you have accountability, you have transparency, so you have got responsiveness,
you have got bottom-up financing, you’ve got money following patients, you’ve got quality systems, you are breaking down barriers between public and private healthcare and I could give you another 10 things that it will do!
Obviously, this increases the amount of money in the healthcare system, which means you can now spend more and improve your quality much quicker. It means that …again someone mentioned that there is predictability if you have
patients who are on health insurance because you have a good idea of the minimum amount of money that you can expect each month. You can take that money to your bank and you can get a loan to put towards the purchase of your
ultrasound machine, etc. As you start using the ultrasound machine, more patients come and you have more money coming in per month.

You then decide to employ a nurse, a physiotherapist, another doctor or whatever …so you see, health insurance is a poor word. I haven’t come up with another name for it, but immediately you say insurance, everyone goes,
“b o r i n g”. However, when you start saying – no it is not insurance, it is financing and it is showing what …(AR: It is innovating healthcare funding). Yes!! It is directing new money into the right places and we could go on like that…trading differences.

AR: Thank you very much. Do not get tired. I’m going to really fuel up your activist spirit and we are coming back to you again and again…

OS: Can I say one word about activism?

AR: Yes you can. You can say plenty of words about activism and how we can all become activists.

OS: Because I wouldn’t be a true activist if I didn’t (say a word). The point is …this is an emergency and the one thing about health emergency is how can we sit here and it is just statistics, but actually if it was a plane crash issue…I haven’t done the calculation (AR – it is every 20 minutes for 24/7) …we would not be sitting here.

We would have done the conference and we would be implementing the outcome of the conference.

We are in the middle of a health emergency,noting that it is getting worse all the time. We are not standing still, we are going backwards.Everyone likes to say 15 percent Abuja declaration – we should be spending that.

The Abuja declaration was 2001. If we didn’t hit 15 percent in 2002, let us say you took the warning, got to 2002 you didn’t hit 15 percent.Let us say you hit 7 percent or 5 percent or the 4 percent, then it means you didn’t spend 10 percent of that budget that you should have spent. Now 2 years later, in 2003, you are no longer at 15 percent but you should have been spending 20 percent. So now, we are over 100% behind!

!! NO!! we are in the ditch and it is being measured by death. Every statistic is a human tragedy, so we need to get that sense of emergency, a sense of urgency, a sense of panic and the only thing that will make that happen is activism. Advocacy is too gentlemanly. We need advocacy. I don’t want to diss it, but you need the people who are going to say – No! I’m going to chain myself to the fence of the National Assembly because it’s about time you pass the new NHIS law …We really need to get mad. Now let me confess. I have been talking about activism but I haven’t started physically being an activist. This is because I am getting the team together, so you are joining the team and let’s get mad, let’s get angry and let’s get some actions!

AR: And don’t forget you know I am a senior lecturer at the university, so I have got a whole bunch of young people waiting. Young people are young. Young people are energetic. Young people are out-of-the-box thinkers. Young
people are digital natives. We will get them all involved. Thank you very much, Dr Soyinka.Always a lovely pleasure to speak with you.
Thank you.


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6th May 2018

BHQJ 2018 ; 001:34-36

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