Structure, Function & Accountability Framework for SSHIP
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The document outlines the structure, functions, and accountability framework for an autonomous agency focused on mandatory health insurance coverage. It details the agency's internal functions, stakeholder interaction, funding sources, and mechanisms for enforcing participation and accountability. The proposed structure aims to enhance efficiency and ultimately facilitate progress towards Universal Health Coverage (UHC).
Structure, Function & Accountability Framework for SSHIP
- 1. Structure, Function & Accountability Framework for SSHIP
- 2. Structure & Function • Autonomous(corporate) Agency backed by law with a competent management & part time representative & independent board with a principal objective for mandatory health insurance coverage for all • The enabling law must align with the NHIS law & NHA 2014-Areas of conflicts are voided. • Board drawn from Labour, Head of service, NHIS, Public. For private sector confidence, the private sector is recommended. • Agency with the respective department to carry out insurance functions with internal audits » Human Resources » Planning, research & statistics » Programmes/operations-marketing, programmes, enrolment & claims processing, Accredutation » Financial management- contribution management, finance & account » Others
- 3. Structure & Function 2 • Functions of provider engagement, policy & regulation, marketing & communication, insurance functions (fund mobilization & Pooling/strategic purchase) • Agency to operate as a QUASI public organisation at the long term • Agency through the departments must ensure compulsion – CIN to enforcement mandatory participation including the organised private sector – Available platforms for collection of premiums, pooling, etc. – Cordinating linkages with LGAs, groups, etc • Interoperable ICT database linked to the NHIS database +HMIS of FMoH • Agency to operate a scheme with various programmes targeting all stratas
- 4. Structure & Function 3 • Pluralistic funding sources (Bismarck and Beveridge models are incorporated)-compulsory budget line, Free MCH, Donor such as SOML, Contributions (progressive?) from Formal & Informal economy, Equity funding, etc • Unitary pool including equity funds for the vulnerables. Pool should as much as possible be shielded from tax, creditors in bankruptcy, etc. • NHIS to support equity funds to expand pool, catalyse investment & efficiency • Funds disbursement to HCFs, recurrents, administration is approved by the board only. Single digit administration advised
- 5. Structure & Function 4 • Single universal benefit package for all residents or groups with top up by TPAs (at least BMHCP)-Not discriminatory, ease of management, etc • Strategic purchasing (using TPAs only for areas of weaknesses) in chosen accredited private/public HCFs for enrolees and targeted vulnerables-community rated, categorical mechanisms • Secondary laws in operational guidelines to further accountability- enrolee forum, etc • Financial audits of operations and annual reports to be rendered to stakeholders (the Government) & NHIS as captured in the enabling law • Sanctions for all erring operators & enrolees. • Linkages with Judiciary, NPHCDA, etc for enforcement of sanctions
- 6. Regulator NHIS Participants (Enrollees) SHIA (Purchasers) Providers (Facilities) KEY STAKEHOLDERS OTHERS SMoH Banks Insurance Coys Ins. Brokers Media, etc
- 7. Accountability • Actors within the ecosystem interact for efficiency and effectiveness ( accountable actor & overseeing actor) • Financial- concerns tracking and reporting on allocation, disbursement and utilization of financial resources. • Performance-demonstrating results in the light of agreed set targets(objectives) • Political - government deliverables from program e.g Impact of program on vulnerables
- 8. Accountability of SHIA-Financial • NHIS/state agency interactions – MIS – Equalization • Representative board accountable to stakeholders-Governor, etc – without those institutions to be regulated – Interactions with laid down rules-Ouorom, etc • Internal management controls of agency – Audits – ICT/Contribution management/finance tracking – Actuarial forecasting – Stewardship in other operations including personnel, materials, equipments & environment • Provider/purchaser-OA including accreditation, reaccreditation & user satisfaction, Reinsurance for improved health care service • Enrollee forum, choice of HCFs to facilitate enrolee voice and power • External Audits & Annual financial reports to stakeholders • Sanctions & Enforcement as well as arbitration/incentives – Deregister TPAs, HCFs, etc
- 9. Financial Indicators 2 Formal contributions Informal contributions Equity contributions & others Admin Salaries Capital HCF SSHI Pool Income Expenditure
- 10. Performance Indicators – Population coverage- number enrolled, no of groupings participating-communities, schools, etc (database) – % out of pocket payment among residents – No covered in the formal Vs the informal sector – No of vulnerables covered – No of public & private facilities participating – Levels of utilization of health services by levels of healthcare – % Increase in funding health by the Agency – Number of payments made (capitation, per diem etc.) regularly made by the Agency to HCFs – User satisfaction
- 11. Performance indicators 3 • Total fund in pool • Administrative charges/funds for service • % investment of idle funds • % recovery of unpaid provider funds, etc
- 12. Closing Remarks The structure, functions and accountability mechanism of SSHIP enhances efficiencies & effectiveness . Proper implementation would definitely accelerate our move towards UHC. .