By Blessing Oladunjoye
Pius Enefiok Nyong is blind and a leg amputee, who is also struggling with kidney problem and high blood pressure. However, the Lagos State Health Scheme, known as ‘Ilera Eko’ comes to the rescue as the scheme is helping Pius manage his health conditions, almost for free. Blessing Oladunjoye writes about how the scheme is delivering quality and affordable healthcare services to vulnerable persons in Lagos state.
It is estimated that Nigeria has 25 million Persons with Disabilities (PWDs). Because disability is extremely diverse, there are some health conditions associated with it, which result in poor health and extensive healthcare needs in many cases; only few disabilities do not require such. Generally, all people with disabilities have health care needs as everyone else. They, therefore, need access to mainstream healthcare services.
Article 25 of the UN Convention on the Rights of Persons with Disabilities (UNCRPD) reinforces the right of persons with disability to attain the highest standard of health, without discrimination. The reality, according to the World Health Organization (WHO) is that few countries provide adequate quality services for people with disabilities.
In Nigeria, inclusive healthcare is poor, both in terms of service and policy provision. Most PWDs in Nigeria rely on families, friends for care, and, in a few cases, the government.
PWDs, in different clusters, have also continued to lament the multi-faceted challenges and barriers that they encounter in accessing quality healthcare services.
Barriers to Quality Healthcare Services for PWDs
PWDs are generally referred to as the poor of the poor, meaning they mostly cannot afford out-of-pocket healthcare services, despite that some of them, depending on their disability type, require more frequent visits to health facilities than others.
For instance, Persons with Albinism (PWA) continuously clamour for subsidized skincare products and support for surgery as skin cancer ravages the community. On the other hand, Persons with Intellectual and Developmental Disabilities (like Cerebral Palsy, Down Syndrome, Autism, etc.), in some cases, have both physical and psychological illnesses and are more likely to require regular expensive medical interventions from therapists (occupational, speech, cognitive behavioural, etc.) and general practitioners.
Beyond financial constraints, attitudinal, physical, and communication barriers are some other factors that hinder PWDs from accessing quality healthcare services. PWDs are “three times more likely to be denied health care, four times more likely to be treated badly in the health care system, and 50% more likely to suffer catastrophic health expenditure,” the WHO says.
LSHS Delivering Affordable, Quality Healthcare to PWDs
Towards achieving Universal Health Coverage, which seeks to ensure that all individuals and communities receive the health services they need without suffering financial hardship, the Lagos State Government (LASG) in 2015 launched the Lagos State Health Scheme (LSHS).
LSHS is a health insurance initiative of the LASG targeted at providing affordable health care services for residents of the state. The health scheme covers registration and consultation, child sickness, chronic disease, emergency care, care of women and newborn babies, admission for at least 15 days, and pharmaceutical care. It also covers various services including eye care, family planning services, child welfare services, hospital care and admission, clinical chemistry, diagnostic radiological investigations, dental care, cancer treatment of early stages 1-2, among others.“
In 2021, the Babajide Sanwo-Olu administration launched ‘Ilera-Eko’, as part of efforts to create more awareness and sensitisation on LSHS.
“…‘Ilera Eko’ is to assist the government in achieving the State’s agenda of providing universal health coverage for residents,” state Commissioner for Health, Prof. Akin Abayomi, had said during the launch in February 2021. Under the scheme, an individual pays N8,500 per annum, while a family of six (father, mother, and four under-18 children) pays N40,000 annually.
As of February 2021, 214 health facilities had registered for the scheme with 142 private and 72 public facilities across the State.
When the LSHS was launched in 2015, all LASG workers were mandated to register to enable them and their families to have access to quality healthcare services, but with the launch of ‘Ilera Eko’ in 2021, the LASG has approved N750 million from the equity fund for the payment of health insurance premiums for 100,000 vulnerable and indigent residents of the state. This has helped indigent citizens to enroll in the scheme without making payments.
“2500 [free] slots were given to PWDs in the state, it was managed by the Lagos State Office for Disability Affairs (LASODA) and it was shared among all the disability clusters across the state,” said Barrister Bolarinwa Salami, Chairman of the Lagos State Chapter of the Nigeria Association of the Blind (NAB). “2500 PWDs were registered in 2021 and the governor paid for them for one year, because the scheme requires annual registration.”
Beneficiaries were selected through PWD associations/cluster groups, and NGOs working with PWDs. Individuals who are not members of associations can also walk into LASODA to indicate interest to be a part of the scheme.
The NAB Lagos Chairman also disclosed that “recently, in commemoration of the governor’s birthday, there was a notification to add 5000 indigent people to the scheme, but we’re not sure if this would be to onboard new people or if it would be to renew the premium for those that have been registered.”
In February 2022, the LASG launched three additional health plans for the scheme to cover more health challenges, accommodate prevalent medical conditions and address the economic realities of residents, especially those in the informal sector. The expansion of the scheme provided a platform for senior citizens in the State and Lagosians in the diaspora to enroll.
Dare Ogundairo, General Manager of LASODA while speaking at a sensitization program to educate PWDs in the state about the health scheme said the scheme would enhance PWDs’ access to affordable healthcare in private and public hospitals in all Local Governments and Local Council Development Areas of the State, adding that it would afford all enrollees the opportunity to enjoy immense benefits.
Indigent and PWD beneficiaries of LSHS
As of the end of July 2022, a total of 629,637 lives are registered under Ilera Eko and there are 1,836,275 registrants under the private health plans that are operational in Lagos. Cumulatively, About 2.5 Million (2,466,512) Lagosians currently have access to health insurance in Lagos State.
Specifically, there are a total of 180,000 vulnerable persons in the state who have been registered in the scheme and specifically 3,438 PWDs have been registered by LASODA so far. There are also about 250 health facilities which are more of the private sector than public health facilities, providing healthcare services to the registrants.
One of the PWD beneficiaries, Mr. Pius Enefiok Nyong, a young man who had complications from Mellitus diabetes type 2, which led to total blindness, amputation of his right leg above the knee, kidney challenge, and high blood pressure, was enrolled in the scheme (for free) in September 2019, when officials of LASHMA conducted house-to-house enrolment of Lagos residents.
However, Mr. Nyong did not activate the service until 2020 when he registered at Dialyzer Medical Centre, Mafoluku – Oshodi, a service he has described as timely and smooth.
“Imagine having to deal with 4 critical health issues, the cost, and expenses coupled with the fact that I do not have any substantial source of income anymore, but the timely intervention of this health scheme has really subsidized my treatment in a very big way,” Nyong admitted.
When his subscription expired in March 2022, Nyong made sure he renewed the service to keep maximizing the benefits.
“I was admitted for serious complications three weeks ago, I was [treated] and discharged without paying a dime, He said”
Another beneficiary, Mr. Taofik Adisa Owoiya, a visually impaired man in his thirties, said he was enrolled in March 2021 through the 500 slots that NAB got from LASODA. Owoiya who has not been to a medical facility since 2015 activated his policy number at Randle General Hospital in Surulere and has since been receiving medical care for high blood pressure.
“Since last year that I registered, I don’t miss my hospital appointments, because they are free and I’ve done about four tests where I didn’t pay a dime,” he added.
For Mrs. H. Wellington, a teacher in a private school in Ikorodu who delivered a baby girl through a cesarean session in April 2022 after subscribing to the scheme for three months with N10,5000.
“I utilized my health insurance scheme in April when I was going to deliver my baby. I was not prepared for a CS because the scan and tests that I had done had shown that everything was fine and that I would have a normal delivery,” she said
“When it was time for me to deliver, I found out that it would be through CS but that the scheme covers it. My bill was over 100,000 but I didn’t pay anything. Before the CS, I was asked to purchase blood and some drugs, and do tests and scans, and I didn’t pay for all of them. The only instance where I had to pay was when I used facilities outside of the hospital where I registered.
“It would have been extremely overwhelming for me to pay all of that money because I wasn’t prepared for CS.”
Mrs Oluwaseun Njoku, a Deaf woman who is registered under the scheme and receiving healthcare services at the Isolo General Hospital recounted how the health insurance scheme was helping her and her children to achieve a healthy living with little or no cost.
Is the Scheme Sufficient? PWDs Need More
Despite the successes recorded, there have been concerns about its scope, coverage, and intent. Salami of Lagos NAB thinks that the percentage of PWDs covered in the scheme is low in comparison to the projected population of 25 million PWDs in Lagos,
“There is no proper accessibility audit for participating hospitals and our challenge of visiting hospitals that are inaccessible remains the same. So, if the hospital that a physically challenged person has enrolled in is not physically accessible, there is free healthcare but such person cannot access any healthcare service because the physical barrier is still embedded.”
He also noted that there is a behavioural challenge in the health centers as some healthcare practitioners are ignorant of how to assist PWDs.
Regarding the inclusion of 5000 residents into the health scheme as part of the birthday celebration of Governor Sanwo-Olu, the NAB chair said such an approach is a charity-based model which negates the human-rights-based model to address disability issues.
He added that “the onboarding seems more like the goodwill of Mr. Governor, whereas, this should be a structured programme for Lagos residents.”
On his part, Mrs. Funmilayo Gbenro (pseudonym) who is a person with albinism said the scheme covers ‘common ailment’ and does not cover the specific healthcare needs of specific disability clusters and that the scheme’s coverage is not sufficient for their healthcare needs.
She explained that for a Person with Albinism (PWA) like her, there is a keen interest to see that the health scheme takes into consideration skin treatment as that is one of the major needs of PWA.
Sharing his experience, Taofik Adisa Owoiya said some drugs were not captured by the scheme, and there are instances when he had to purchase the drugs outside of the hospital facility. Plus some beneficiaries have been told that their policy has expired and has not been renewed by the state government, while others are yet to get their policy number and some who got theirs have not been able to activate it. He said it is not clear if the money paid by the LASG in that instance has been wasted.
Also affected are PWDs who registered as a family instead of individuals, who are yet to get their policy number, which means the payment covers only individuals whereas, PWDs have families.
Also, Mrs. Wellignton said it was extremely difficult for her to get a health center within close proximity to her, she thinks the participating hospitals needed to be expanded to ensure it is within reach to people.
A Blind woman who simply identified herself as Mrs. N.O. was worried that private hospitals under the scheme are not as efficient as public hospitals. She narrated that she would always receive the same drugs for different ailments and would be told that is what her health policy covers.
“I am not getting the best from that private hospital and I cannot switch my health provider in the middle of my scheme. Now, I have to work out how to register with a General Hospital that is not too far from me,” she added.
Mr. Afolabi Fajemilo, the Executive Director of Festus Fajemilo Foundation, a disability-focused organization working with people living with spina bifida and hydrocephalus in Nigeria, said as a service provider for PWDs, his organization nominated 25 beneficiaries (children with spina bifida and hydrocephalus) as requested by LASODA but that they were asked to pay after receiving their policy number.
Another limitation of the LSHS as shared by a government official who preferred to be anonymous is the chances of duplicate registration.
She noted that “the scheme was compulsory for all government workers who would be required to register their spouse and children.
“So, if I register and my husband is a staff of the LASG, he would be required to register and his salary would be debited. This means both of us would have full health insurance packages but we can only use one, that is a duplication that should be addressed,” she added.
Issa A. Usman, the Chairman of the Lagos State Association of the Deaf lamented that Deaf persons in the state who are not officials of the LASG have not benefitted from the scheme despite that their details have been submitted to LASODA as requested.
Usman said “the Deaf cluster submitted 500 forms as provided by LASODA for the free healthcare scheme, we did our part and submitted the details. Up till now, none of the Deaf people have received any update from LASODA concerning it. No Deaf person has come out to say he or she got free healthcare attention through the scheme.”
LSHS Beyond the Current Administration
Though the LSHS has been in existence since 2015, the current administration of Governor Babajide Sanwo-Olu birthed the equity fund/payment of health insurance premiums, whereby indigent citizens were onboarded, to make healthcare accessible and affordable to them. However, there are concerns about the continuity of this scheme, specifically the payment of premiums, when Governor Sanwo-Olu is out-of-office.
Speaking in an exclusive interview with BONews Service, the General Manager of the Lagos State Health Scheme (LASHMA), Dr. Emmanuella Zamba explained that there were ongoing efforts to review the existing LSHS policy to ensure it meets the current realities and future exigencies and such would cater to the emerging health needs of Lagosians.
Though the vulnerable person being catered for seems to be low, Dr. Zamba explained that “the 1% equity fund can only cover a stratum of about 72% Lagosians living in poverty, but we have begun to explore innovative approaches to generate more resources and to onboard more vulnerable people into the health insurance premium.”
Speaking about how long beneficiaries can benefit from the scheme, the LASHMA GM said the “health insurance premium is for the poor of the poor but we are also working with relevant agencies to link these beneficiaries with empowerment opportunities so they can be economically empowered, and thus, exit the scheme. We don’t want them to remain poor forever, which means they cannot be a beneficiary of the scheme forever.”
The LASHMA GM also recorded that it is difficult to get the buy-in of people into the health scheme generally because of the poor attitude to insurance. She acknowledged that the health scheme is a work in progress which could have some shortfalls but also noted that there has been low feedback from beneficiaries, which would make it difficult to track and address some of the challenges that are being experienced.
Insights for Improvement and Replication
The LSHS is an initiative that should be replicated in different climes to ensure that the most vulnerable in society are able to access affordable and quality healthcare services towards achieving Universal health coverage and SDG 3.
Salami believes that some of the current flaws in the LSHS can be addressed through the setting up of appropriate structures within the implementing agency, LASHMA, and that disability issues should be addressed from a human-rights-based approach whereby PWDs are treated as humans who have rights, other than objects of charity that should receive a token.
“LASHMA should have a disability desk or unit which would effectively manage disability issues within the operations of the agency. Such a desk or unit would be responsible for the enlightenment and training of its staff and participating hospitals to ensure that the healthcare services are not just made available for PWDs, but that we are able to access them truly,” he said.
Salami said “the disability desk or unit can also conduct accessibility audits of hospitals and provide a checklist of hospitals that are accessible for PWDs.
Mrs. Wellington also recommended that medical facilities in suburbs and hinterlands should be deliberately targeted and onboarded as service providers so that the true intent of delivering healthcare services to indigents and vulnerable citizens is achieved.
“If the healthcare facilities that are part of the scheme are far from us, we won’t be able to go, and it is not all of us that would go to big hospitals within the neighborhood, because I imagine that their prices may be high and it may affect what our health scheme would cover. I am not sure of this but it is advisable that hospitals in local areas should be part of the scheme,” she added.
This story has been made possible by Nigeria Health Watch with support from the Solutions Journalism Network, a nonprofit organization dedicated to rigorous and compelling reporting about responses to social problems.
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