PharmAccess / Hygeia / Kwara State

Transcription

1 PharmAccess / Hygeia / Kwara State Lessons learned, the hard way Burundi, April 30,

2 1. Context What Donor-funded project to provide subsidized health insurance to low-income people Also focused on improving the Supply-Side (standards setting and investment) Primary Care, including Maternal Care, HIV & AIDS, Chronic care and Minor surgery Where Lagos (urban) & Kwara State (rural), Nigeria When Who Since 2007 Health Insurance Fund (HIF), Fund Manager on behalf of Dutch government Kwara State, co-funder and project owner PharmAccess, project management on behalf of HIF Hygeia, local insurance company / HMO Hygeia Community Health Care, separate entity 24 healthcare facilities AIID / AIGHD, research institutes hired by HIF for impact analysis 2

3 2. Contextual challenges Initially managed as a form of Business Process Outsourcing They are an insurance company, they know what to do However, insurer had no experience with low-cost, high-volume policies No advice from IT department asked (e.g. on data requirements ) Many partners in the chain Communications Objectives Research vs Commercially-Viable vs Capacity-Building project Much more data was asked for than needed commercially No incentives built in for providers to submit all that data The tracks were pretty much laid as the train sped forward Urban vs Rural Lagos vs Kwara o 3

4 3. Technology At first Started out with paper claims forms Data collected / transferred via Excel sheets No coding used, no business rules enforced Managed outside existing application for corporate clients Then Now Coding introduced Excel replaced by Access (providing some control on data quality) Data management training introduced Back office: Proprietary software purchased (no expert advice asked, not linked to financial system, not flexible, interoperability a challenge) Frontoffice: Tailored solution, financed by ILO (built from scratch, adequate problem analysis at last) 4

5 5. Technology Envisaged Enrollment and Premium Payment in the field Mobile Agents Shops Owners/ Village Heads Agents/Enrollment Officer Push Enrollment Data Insurer Back Office Operation Business Intelligence Reporting Tools SQL2008/12 database Back office Administration Updated Enrollment Data Changed data, Utilization, Claims Primary Care Provider Enrollment Enrollee eligibility validation Utilization and Claims Business Intelligence Reporting Tool SQL/Express Web based Application (offline/online mode, open architecture, end-to- end with limited integration ) Streamlined business processes (improved turnaround time) Less data input errors (drop menu, less text, abridged coding system) Improved eligibility management at the point of access 5

6 5. Technology challenges At first Data quality rather poor Patient IDs too long, leading to typos, leading to pregnant males No coding means no tallying / counting (e.g. 10 ways of writing malaria ) Then Now Internet connections for facilities no longer budgeted in, hence dropped MS Access application not robust enough for large-scale data processing Data duplication / redundancy (i.e. poor linkage of utilization & claims data) Vendor locked-in backoffice solution (proprietary legacy software) Low IT / computer proficiency at healthcare facilities and insurer Low internet penetration at healthcare facilities (especially in rural areas) 6

7 6. But... > 70,00 people in the rural program Investment leveraged 10 times Kwara State government now taking over funding, presently at 60% SafeCare quality approach pioneered in this project now the national / federal standard in Kenya, Tanzania, and some states in Nigeria As a result of lessons learned, we helped Ghana & Kenya develop a joint e-claims standard In Ghana, the first 50,000 e-claims have been exchanged / processed 7

8 About PharmAccess Group PharmAccess Foundation: Health Insurance Fund: Medical Credit Fund: SafeCare Standards: 8