1. Allied Services
CBSHIP: MHAs and CSOs
Presented at In-house Departmental Training
D r. Ya k u b u A d o l e A g a d a - A m a d e
Assistant General Manager
HMO & Allied Services Division
Department of Standards & Quality Assurance
National Health Insurance Scheme
Abuja, Nigeria

2. Outline
– Introduction
– MHA and CSOs
– Conclusions

3. • Introduction
– P ro g ra m m e M a n a ge rs
– Te c h n i ca l Fa c i l i tato rs
– C o m m u n i t y B a s e d I n s u ra n c e S c h e m e

4. Introduction
• Programme Managers (PMs)
– Bodies responsible for
• community mobilization and sensitization
• Benefit package of the programme
• Determination of Contribution rate
• financial management
• Administration
• Monitoring of HCF.
– They include
– Board of trustees (BoTs), HMOs, CSOs, Technical Facilitators (TFs)
etc

5. Introduction
• Obligations of PMs
– Conduct advocacy outreaches targeting policy makers at State and LGA
levels
– Conduct advocacy activities to sensitize and mobilize community,
religious and opinion leaders and the leaders of groups, to generate
awareness for the establishment of CBSHIPs
– Conduct IEC activities to sensitize and mobilize community members
and occupation based groups (including cooperatives) to buy-in to
CBSHIP
– Generate 10 and 20 data (surveys, etc) for the purpose of programme
planning, monitoring and evaluation

6. Introduction
• Obligations of PMs contd.
– Determine benefit package and contribution rates in
consultation with NHIS and community members
– Sign contractual agreement with participating communities and
occupation based groups
– Pool contributions collected
– Ensure prudent financial management of pooled resources,
– Sign contractual agreements with service providers
– Purchase health care services on behalf of participating
communities and occupation based groups
– Conduct medical auditing and quality assurance

7. Introduction
• Obligations of PMs contd.
– Conduct health promotion and prevention activities
– Conduct capacity building activities for the BOTs and participating HCF
– Supervise and monitor Programme activities
– Generate and contribute additional funding into CHISNEF
– Assist new participating communities to set up Board of Trustees
(BOTs)
– Send regular reports/feedback to the NHIS, its agents, communities &
faclilities.

8. Introduction
• Technical Facilitator (TFs)
– NHIS accredited bodies engaged to provide both initial and
on-going technical facilitation (or programme management
where applicable) for the establishment and
implementation of CBSHIPs.
– They include
• all NHIS accredited HMOs
• Civil Society Organizations (CSOs)
– Non-governmental organizations (NGOs),
– Faith Based Organizations (FBOs)
– Community based Organisations
• limited liability companies, or companies limited by guaranty.

9. Introduction
• Functions of Technical Facilitators (TFs)
– Generate 10 and 20 data (surveys, etc) for the purpose of
programme design and monitoring
– Determine benefit package and contribution rates in
consultation with community members
– Conduct medical audit and quality assurance
– Conduct capacity building activities for the BOTs and
participating healthcare faclilities
– Supervise and monitor Programme activities
– Assist new participating communities to set up BOTs
– Send regular reports/feedback to the NHIS, communities &
faclilities

10. Introduction
• Definition of CBSHIP
– Not-for-profit health insurance programme for
• a cohesive group of households /individuals or
• occupation based groups,
– Formed on the basis of
• ethics of mutual aid
• the collective pooling of health risks,
– Members take part in its management

11. Introduction
• Management Models
– Management Models available for user groups
• BOTs as PM
• BOT as PM with external TFs
• TFs as PM.
• Note: BoT is Board of Trustee

12. • Mutual Health Associations
• &
• Civil Society Organizations
– D ef i n i t i o n
– B e n ef i t p a c ka ge

13. Definitions
Mutual Health Associations
(MHA) Civil Society Organizations (CSOs)
• privately or publicly incorporated • CBOs and Faith FBOs etc are
body registered by NHIS solely to
access health care services the multitude of
through HCF accredited by NHIS associations/ organizations
• run by a BoT elected by
members. around which society
• non-profit organization voluntarily organizes itself
• formed on the basis of solidarity and represent a wide range
and the collective pooling of
health risk by community of interest
members • accredited by NHIS as PMs
• governed by the constitution/
bylaws and members take part in or TFs in the CBSHIP.
its management.

14. Conditions for Accreditation
• Register with the CAC
• Original Certificate of Incorporation and Incorporated Trustees
Form shall be sighted and verified.
• Constitution/Byelaws
• Complete the prescribed NHIS application forms, providing the
following information:-
– Composition of the BoT
– Names and addresses of the principal officers of the BoT
CSOs
• identify with Local/State Government as applicable.
• Complete the prescribed NHIS application forms
• Composition of the Trustees

15. Conditions for Accreditation
• Possess necessary staff and infrastructure including
computerization
• Pay the stipulated registration fees for guidelines and other
sundries
• Maintain current accounts with NHIS-accredited banks
• Evidence of registration with relevant professional/occupational
bodies (where applicable.
• Evidence of Audited Account/Statement of Affairs
CSOs
• Min working capital of N5M where the TF functions as PM
• Re-insurance with an NHIS accredited ins co, where the TF functions as
PM

16. Procedure for Accreditation
MHA/CSO
Evidence of visited by NHIS
current tax for
clearance of Accreditation
members of
Basic the BoT
registration doc,
such as the CAC Payment of
reg fee
A copy of the payable by
Application for byelaws, rules
accreditation any MHA or
and regulations CSOs shall be
signed and
verified by names, N10k
authorized addresses and
persons official positions
of Mgt of the
MHA/CSOs
CSOs
• The CSO etc shall pay an accreditation.

17. Rules and Regulations – MHA &CSO
• Registration with the NHIS
• Issuance of accreditation letter by NHIS
• Accreditation is for a period of 2 years at the first instance.
• Can not discriminate against any member on grounds of race,
religion, gender, marital status, or ethnic background.
• Staff or appointed agents of NHIS to visit any MHAs/CSOs and
assess its structure and performance.
• bank account with any bank from the list of NHIS-accredited banks.

18. Rules and Regulations – MHA &CSO
• No person shall have claim on the assets or rights over MHA/CSO
• Accreditation of any MHA may be cancelled if
– the accreditation is based on fraudulent misrepresentation,
– the Association ceases to exist, or is unable to maintain the financial
conditions stipulated by the NHIS.
• Upon Accreditation,
– MHA/CSO shall enter into an agreement with a chosen HCF, after due
negotiations.
– MHA shall sign MoU with the NHIS.
– No MHA shall be allowed to invest its funds.
– Every MHA shall evolve an appropriate dispute resolution mechanism, which
shall be made known to its members.

19. Rules and Regulations – MHA &CSO
• In collaboration with NHIS, shall set up a QA Committee to ensure
quality of service by the HCF
• The NHIS shall carry out periodic evaluation exercises for accredited
MHA/CSO and assess their level of performance and efficiency
• Identity cards shall be provided by the NHIS and its agents to
members at a cost.
• The BoT shall meet at least monthly while the general meetings of
the ORG shall be quarterly.
• Every MHA/CSO shall set up a Health Education Committee.
• The NHIS and its agents shall attend the meetings of MHA and BoT
as observers.

20. Conditions for Re-accreditation of MHA/ CSO
• The MHA/CSO etc conducting its operations in Note:
accordance with sound HI principles for a period of 2 • When Trustees of a CSO are
suspended, the Scheme shall
years act as receiver from the date
• Evidence of consistent and prompt payment of of suspension pending
resolution of the issues
capitation to the facilities and/or settlement of fee involved.
for service claims • No MHA/organization shall
• Non engagement in fraudent activities elect or have in its board, if
he/she:
• Compliance with provisions of the NHIS Op Gd and • becomes of unsound mind , or
as a result of ill health, is
the contractual agreement. incapable of carrying out his
• Adequate and regular conduct of social responsibility duties
• Is convicted of any offence
• Meeting re-accreditation requirements involving dishonesty or fraud
• Management with regards to: • Is not a fit and proper person
for the position
– Trustees meetings • Is guilty of serious misconduct
– General meetings in relation to his duties
– Joint meetings with facilities and enrollees • In the case of a person with
professional qualification; has
– Adherence to Association conditions of service e.g. regular been disqualified or suspended
payment of Trustees allowance from practicing his profession
– Compliance with the judgment of the arbitration panel where in Nigeria by the order of any
applicable competent authority made in
respect of him personally.

21. Membership
• Voluntary and open to all residents (families) of the
participating communities or occupation based
groups (including retirees).
• The family or individual members shall be the unit of
registration.
• In order to achieve a critical pool of funds to ensure
financial viability, as well as to address the problem
of adverse selection, communities or occupation
based groups shall have at least 50% of members
willing to participate (or a minimum of 500
members).

22. Benefit Package
• The benefit package shall reflect
– Preventive
– Promotive
– Curative components of health care delivery.
• It shall aim at 10 and 20 care,
• Taking into cognizance
– the prevailing local morbidity and mortality profile,
– pre- & post-natal care, normal delivery, child welfare
services (including immunization),
– family planning and health education services.
• The Trustees (BoTs) and NHIS shall work to adopt a
suitable benefit package.

23. Functions of MHA/CSO
Function of BoTs
• Conduct mobilization & sensitization of community members
• Register and regularly update the record of members
• Collect contribution from participating members and keep record of same.
• Pay contributions collected to TFs in TF- managed programmes,
• Pay Healthcare Facilities in BoT-managed programmes
• Screen members to benefit from Community Health Insurance Safety Net
Fund (CHISNEF)
• Ensure that there is no abuse of the system
• Support health promotion and prevention activities
• Provide community level quality assurance
• Organize regular community meetings (for feedback),
• Send regular reports/feedback to community members, facilities, NHIS
and TFs where applicable.

24. Source of fund
• Contribution/Premium
– actuarially determined in relation to health need and
benefit package.
– flat rate fee per individual household member or member
of an occupation based group and paid in cash annually or
quarterly in advance as may be agreed by the enrollees,
Trustees and NHIS.
• Donations (Local and International)
– Trustees may seek for donations/grants by way of formal
launching/fund raising events
– by targeting individuals, governmental and CSOs, including
private companies, with the aim to boost the financial
base of the associations.

25. Remuneration
CSO etc
• As much as voluntary work is encouraged,
– CSO etc shall be entitled to admin charge to be determined by
NHIS.
– For CSOs, admin costs of TFs shall be funded by volunteer
philanthropic individuals, OPS or from a percentage of CHISNEF
set aside for the management of CBSHIPs.
Remuneration of BoT Members
• As much as voluntary work is encouraged,
– Members of the BoT shall be entitled to monthly remuneration
as determined by the members of the MHA/organization.
– Any such remuneration to the Clerk must take into
consideration the logistics of carrying out functions assigned to
him/her.

26. Guidelines for BoT
• Resident members of the community,
• elected in a democratic manner acceptable to the
generality of the community members,
• operate in line with a constitution developed and
adopted by the community members,
• Register MHAs/Organizations with Local/State
Govt authorities and CAC as applicable and seek
accreditation with the NHIS.
• Tenure
– BoTs tenure shall be as enshrined in the Association’s
Constitution/Bye Laws.

27. Merger and Acquisition
• No MHA shall merge with, transfer to or receive from any
other MHA/CSO, its business or lives without the approval
of the Scheme in writing.
• The BoT/Trustees however, shall retain the power to
register more enrollees to the benefit of the MHA/CSO.
• Considering request for (1) above the Scheme may request
for
– a draft of the agreement or deed under which it is proposed to
effect the merger, acquisition or transfer.
– Auditors report of each of the MHAs/CSOs
– A report of the proposed merger or acquisition.
• The Scheme using its discretion may approve or reject the
merger, or acquisition.

28. Exit from the Scheme
• MHAs/CSOs exiting the Scheme shall:
– Give three (3) months written intention notice to the Scheme and HCF
– submit a plan demonstrating how its outstanding claims and
obligations will be settled.
– Submit an actuarial analysis of the adequacy of reserved resources to
pay HCF claims.
– The MHA/CSO shall accord all its enrollees and HCF the necessary
rights and privileges due to them under the Scheme within the
3months period of this notice.
Note:
• In the event of winding up, the following priority shall be followed
in settling of debts:
– Capitation to primary HCF
– Fee-for-service to secondary/tertiary HCF

29. Conclusion
– CBSHIP is key to Achievement of Universal
Coverage in LICs and MICs
– MHAs & CSOs are key to the proper operation of
CBSHIP; as programme managers and technical
facilitators
– Properly managed MHAs & CSOs are important to
achievement of universal coverage in Nigeria

30. Otutuo
Msugh ma
O ̣se
/ E se
Thank
Sɔsɔŋɔ Useko
You
Anya
Agba
Nagode
Reference
1. National Health Insurance Scheme (2012): NHIS Operational Guidelines .Focal Point Publishing, Abuja, Nigeria