17 July 2017

Nigeria: National Health Insurance (NHIs) and Matters Arising

National Health Insurance Scheme as stated in their website was "established under the National Health Insurance Scheme Act, Cap42, Laws of the Federation of Nigeria, 2004, is aimed at providing easy access for all Nigerians at an affordable cost through various prepayment systems. NHIS is totally committed to securing universal coverage and access to adequate and affordable healthcare in order to improve in order to improve the health of Nigerians, especially for those participating in the various programmes/products of the scheme".

What captured my attention in the preamble are two points quoted as follows :(" is aimed at providing easy access for all Nigerians at an affordable cost) and "NHIS is totally committed to securing universal coverage and access to adequate and affordable healthcare' 'Do you know that NHIS scheme has the potential to provide health care services to all Nigerians and definitely, a major driving tool for achieving universal health coverage. However, the scheme since introduction 13 years ago covered only 1.5% of the Nigerian population. From conception, the programme was lopsided in favour of federal government staff. Later, some state governments joined albeit dropped along the line. The biggest question in my mind is why such a laudable project failed to achieve its desired goals. To answer the above question, we need to know how the scheme works and then try to trace the root cause of the problem. NHIS is a regulatory body that supervises the operation of health insurance in Nigeria. The key stakeholders are the Health Maintenance Organization (HMO) and accredited NHIS hospitals. The end -users registered with any NHIS-accredited hospital through their HMOs and pay only 10% of charges for services provided. The HMOs claimed the users' bill from NHIS. The flow chain thus entails government (NHIS)-HMOs-Hospital.

The users are enrolled at place of their work as a federal government employee or as a staff of any agency that joined the scheme. The NHIS made attempt to co-opt non-formal sector into the programme through such initiatives as community- based social health insurance scheme, tertiary institution social insurance scheme, public-private partnership social insurance scheme and vulnerable group social health insurance scheme. These are novel ideas and ordinarily, by now, everybody should have covered by the scheme. However, only 1.5% was covered. Nigeria is good at presenting neat paperwork but with the ardent inertia of political will for full implementation.

In my opinion, the factors mitigating the wider coverage of the scheme have to do with the major players of the scheme. When the government introduced pension scheme, it made it mandatory for everybody in the public and private sector to participate. However, NHIS was made optional and some government organisations have their health care services separate from NHIS. Many private organisations have no organised health insurance for their employee because they were not mandated by law. Failure of government to make health insurance contribution compulsory for both private and public sector has resulted in haphazard implementation of the programme. Furthermore, the programme was not covering enough because it was not conceived to cover enough from the beginning.

Why do you target only civil servants and their families? How many per cent of Nigerians are civil servants? When it comes to the election, the government can do everything possible to cover the remotest area to get their votes but when laudable projects such NHIS are being formulated or developed nobody considers the down-trodden and masses on whose shoulders the politicians climb to power. At least, a sensitive government should consider under5, pregnant and breastfeeding mothers as well as aged and people with disabilities.

The community- based social insurance scheme is perfect initiative but was an afterthought and not easily practicable without government support. Some state governments attempted free maternity and child health care services in their states but failed because of lack of consolidated structure on ground to sustain it.

Health insurance should have been a better option in such circumstances. Federal government pledges 5000 naira social services for the unemployed youth and the masses. This is a good gesture but the fund should have been diverted to provide health insurance to the populace. The insurance registration can be merged with national ID card registration, as you get your national ID card; the national health insurance card follows.

Of course this should be done along with biometric data capture to check mate duplication. Even the formal sector, many eligible staffs were not enrolled due to inefficiency and bureaucracy of the registration process. It takes nothing less than 6 months to one year to get registered. Additionally, the national health insurance scheme has not done enough publicity to market the products available in the informal sector. No enough radio jingles and TV adverts to educate the public about the scheme except sporadic radio interview with the personnel. They failed in their supervisory role, dine and wine with HMOs.

The second major players are the powerful health maintenance organisations which serve as middlemen between the government and hospital. Supposedly, they represent the interest of the enrollees. The big question is how many enrollees even know their HMOs? The HMOs have no business with you even-though they thrive on your capitation. The usual practice is that a particular institution will be allocated to particular HMOs and therefore all staff therein has to register under the company. Unlike pension scheme, where staff has a chance to interact with his or her Pension Fund Administrator, HMOs are invisible and too arrogant for that. Many of them have only one office in Lagos but their area of jurisdiction covers the entire country.

When federal government banned the use of unregistered SIMS, the telecommunication companies reached out to people to register them. Our invincible HMOs will never do that because they have institutional allocation, not individual allocation. IF you like stay there, at the end of the month they get paid three-month capitations in advance. There are many instances hospital rejected patients because the HMOs refused to pay them despite collecting capitations. There are instances where HMOs are not reachable in a critical situation where they are needed.

I don't want to talk about the corruption allegation running into billions of naira against the HMOs, it is already in public domain and various investigative panels have been set up to unearth the truth. I personally believe HMOs have nothing to do in the formal sector, they should be moved to informal sector to help government mobilise more enrollees or be scrapped completely.

The hospitals are other players that sabotage the scheme in their own way. Some hospitals in order to maximise gain, capitalised on the fact that branded prescriptions are not allowed in NHIS prescription, to stock cheap and substandard drugs for the patients. For example, you hardly be given Xalathan, Augmentin, and Rocephin as NHIS patients but rather some unpopular products with no proven efficacy were dispensed. This in addition to general unfriendly treatment attributed to Nigerian health workers.

The National Health Insurance Scheme is our own version of NHS, Medicare and has the potential to provide access to quality health services to all Nigerians. We should not allow the few players to deprive the majority accessibility to health care. The on-going crisis is an opportunity to undertake a full blown investigation into the scheme; anybody found wanting should be made to face the music.


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