25 December 2012

Nigeria: NHIs - 'Compulsion, Subsidy Key to Universal Coverage'

Dr Abdulrahman Sambo is the acting executive secretary of the National Health Insurance Scheme. In this interview with Ruby Leo, he says compulsion and a subsidy are key to attaining universal coverage as most Nigerians will be unable to pay for their health insurance.

What has been happening at NHIS since you took over 10 months ago, activities seem to have come to a stand still?

We have been working. We have consolidated what we started, and have initiated a number of projects and programmes. As you recall December last year, we launched the voluntary contributors' scheme and the community-based insurance, which is being implemented. We have also engaged a number of states because we realize that the only way we can attain universal coverage is by modifying the mode of operations of NHIS and redefining the roles of various stakeholders.

To achieve universal coverage, we need to compel people--those who can contribute--to contribute and pay subsidy for those who can't. Compulsion and subsidy are the key to attain universal coverage. To achieve that, we reviewed the NHIS mode of operations with active collaboration of the National Assembly. This has been on since 2005, but this year, during the past ten months, we have been able to carry the bill to second reading at the House of Representatives, and the Senate has also taken it up. It was tabled before the Senate and will soon go through second reading.

It was started in 2006, abandoned along the way and reactivated within the past ten months. We have signed an MOU with International Finance Corporation (IFC) and they have given a grant to NHIS. 60% of the funds for the conduct of the review of the NHIS will be financed by the International Finance Corporation, while 40% is from the NHIS.

In July, the IFC paid close to $800,000 for the implementation of this project. A company, Accenture, was engaged by both the IFC and NHIS and they have started work aimed at doing a holistic review of the scheme.

One of our challenges in NHIS is basically people's expectation from the scheme. People see NHIS as the organisation that should provide care for all Nigerians, forgetting it is a health insurance agency. In insurance people must contribute. You either do, or somebody does on your behalf. The federal government is paying for its employees and we have covered 100% of them. The state government and employers of labour will have to pay contribution on behalf of their employees. The ordinary man on the road who is self employed should be able to pay for himself through the voluntary contribution service we initiated.

However, a vast majority of Nigerians are unable to make the contribution, and these are the groups that require subsidy. Who should pay it: the state, local or federal government? Or maybe a combination of the three. In this, the health bill would have come in to assist those who cannot contribute. When it is signed into the law, we will have funds to help those who cannot make any form of contribution.

We have also reviewed the performance of health maintenance organisations under the NHIS and engaged Price Water house Coopers to assess HMOs toward accreditation. We have reviewed the accreditation to promote solid, viable, strong, competitive HMOs in the country.

We have also examined the providers, their role in delivery of care under the NHIS, and they are stronger, more viable, more apt to the complaints of enrollees.

For enrollees, we have examined their various complaints. We have designed an IT platform where individuals can update their records, change their hospitals, add or remove dependants. In short, you manage your own account. We would have opened up the online registration and that would ease the difficulties staff face in registration. But the greatest challenge there is lack of database of civil servants.

But working with the office of the AGF, we will be able to open that gateway for staff to register online. Though as you know, voluntary contribution registration is online.

Coming to the community-based contribution: last week, we flagged off one in Dutsen-ma local government. We slightly modified it in Katsina, which I think should be copied in other states. The local government is now serving as the main driver of community health insurance, with the respective village and district heads. The local government is paying for those who cannot afford to pay, as identified by the district and village heads. Those who can afford to pay are being compelled by the community to make their own contribution. So we have three pools of enrollees: the poor, those paying from their pockets, and those supported by the NHIS--that is pregnant women and children under five. We are doing that in one local government per state.

Another model would have been flagged off in Kaduna which would be exclusively owned by the community. The subsidy is coming from the community. The rich are paying for the poor.

In Sokoto we saw a large number of community initiatives, same as in Lagos and Kwara. We have signed an MOU with Abia state government to commence both formal sector and community based insurance. We discussed with the governor of Ekiti and he is coming on board. Quite a number of states are willing to come on board.

Lets talk about the MDG programme for pregnant women and children under five aimed at free care, are you planning on cascading to other states, or has it run its course?

When we started in 2008, we were in eight states. Unfortunately we faced a challenge this year, non allocation of funds in the budget for the programme. We have been in lengthy discussions with various stakeholders and the ministry and National Assembly are going to support the NHIS. So in 2013, we are going to restart the MDG project with a little sustainability. We are working with states willing to pay their counterpart funding.

People complain about the way HMOs handle their care. Is there any mechanism to check their excesses?

Excesses--I wouldn't want to use that word. That's what people say but when you ask them, they can't come up with something concrete. It's just a perception but I agree a lot has to be done to improve . There is a strong perception out there that HMO business is very easy and lucrative; it is not so. HMOs are supposed to register people, pass the information to NHIS for production of ID card and subsequent release to the enrollee. They are to ensure the enrollee is treated according to the benefit package and is not short changed. They are supposed to make payment, taken from NHIS, to the hospital. They are implementers of the formal sector scheme under regulation of the NHIS.

The review of their accreditation is to ensure only very serious HMOs are in the industry. We have had cause to sanction a few but we feel once they are strong and viable, there will be less problems. We reviewed their initial capital to start the business, looked at qualification of principal staff and officials, and re-caterogised them. Before now, there was just one nationally, making it expensive to operate. Now we have national, zonal or state based. If you feel your strength is in a particular state, you will be confined to that state, and the requirements are slightly different and lower than that of the national.

You flagged off the community health at Isanlu last year. Any positive impact on the community?

The impact is being reviewed currently. Our discussion with them and monitoring has seen significant impact on the health status of people in Isanlu and has greatly minimized expenditure especially for those in the programme. We started with about 500, but now there are over 10,000 people registered. When you see people coming out daily, you know it is a popular programme. It is gratifying that other communities are picking up the initiative.

In most countries of the world, social health is financed by government. That is why I believe unless we have a constitutional change to compel the various tiers of government to finance social services, not just health, we are unlikely to attain universal coverage. Unless we have subsidy, we are not likely to have universal coverage, but who should pay the subsidy is a constitutional issue.

No amount of amendment of the NHIS act will make state governments pay. I don't think we can compel states to spend money on health, education or any social service, based on the provision of the 1999 constitution.

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