The National Health Insurance Scheme (NHIS) introduced by the Federal Government in 2005 for the purpose of ensuring universal access to qualitative healthcare services for the citizenry has performed abysmally below expectations, and therefore needs to be re-positioned in order for it to deliver on its mandate. PharmaTimes takes a historical and performance assessment of the scheme so far, and seeks to proffer solutions for a more workable system that the country really deserves.
In the last 12 years that the scheme began operation, a greater percentage of the Nigerian population have not benefitted from its services and yet its future appears to be hanging on the balance as a result of numerous controversies trailing its operations.
For instance, in March this year, the Senate set up an ad hoc committee to investigate allegations bordering on financial and administrative abuses levelled against the executive secretary of NHIS, Prof. Usman Yusuf by a member of the upper chamber of the national assembly, Senator Garba Marafa, representing Zamfara Central Senatorial District.
Similarly, in June this year, the House of Representative Committee on Healthcare Services, held a 2-day public hearing to ascertain the compliance rate of Health Maintenance Organisations (HMOs) to the NHIS contributions and utilisation of funds by the healthcare providers as well as inhumane treatments meted out to enrolees.
At the opening of the public hearing, the minister of health, Prof. Isaac Adewole, had said that the continued existence of HMOs in the operations of NHIS was no longer necessary following the alleged mismanagement of funds to the tune of N351billion paid to them for effective and efficient healthcare delivery in the country.
Also in his submission at the public hearing, the executive secretary of NHIS had said that only 1.7 per cent of the Nigerian population had been covered by the HNIS in the last 12 years, alleging that the HMOs were sabotaging the scheme by withholding payments to healthcare providers even when they have collected funds from NHIS.
He also alleged that HMOs were involved in what he called padding, just as he disclosed that his administration had uncovered about 23,000 ghost enrolees and however, promised to review the operations of the scheme to make it work for the public.
Objectives of the NHIS in Nigeria
At inception in 2005, the NHIS was set up to achieve the following objectives:
To ensure that every Nigerian has access to good health care services, protect families from financial hardship of huge medical bills, and to limit the rise in the cost of healthcare services, ensure equitable distribution of healthcare costs among different income groups, and to maintain high standards of healthcare delivery services within the scheme.
Others include, ensuring efficiency in healthcare services, to improve and harness private sector participation in the provision of healthcare services, ensure equitable distribution of health facilities within the Federation, ensure appropriate patronage of all levels of healthcare and to ensure availability of funds to the health sector for improved services.
The scheme from available statistics is far from meeting an appreciable level of these set objectives and at the last count Nigeria, ranks among the least on the list of countries around the world with good compliance rate in universal health coverage.
A number of factors have combined to slow progress in the efforts by authorities in the NHIS to deliver on their mandate. The major factor is lack of political will by authorities in the scheme to plug the loopholes that gave rise to the kind of monumental fraud allegedly perpetrated by the HMOs in the last 12 years.
There is also the challenge of low level of penetration of the scheme across the different interest groups in the country. Specifically, the informal sector which accounts for the greatest percentage of the Nigerian population has not been captured in the scheme.
Irregular payments to participating health care providers by HMOs continue to impact negatively on the enthusiasm of providers and quality of care enrolees receive from them.
The participation of states and local governments is very low when compared with what obtains in other African countries like Kenya, Ghana and Rwanda, among others. State and local governments are closer to the rural dwellers that constitute a significant percentage of the vulnerable group and must be carried along.
Stakeholders in the health sector have also criticised the template being adopted by NHIS in the execution of the exercise. For instance, the President of the Pharmaceutical Society of Nigeria (PSN), Pharm. Ahmed Yakasai, believes that the challenges confronting NHIS in making progress with the scheme is fundamentally at two levels which he described as indiscriminate capitation of facilities and the employment of unlawful payment mechanisms.
In a recent interview with a national newspaper, the PSN boss said that in the ideal situation, the norm in social health insurance and managed care is to capitate primary providers which includes general practice doctors/clinics or nurses/midwives who own nursing and maternity homes.
The primary provider, he noted, is perceived as the gatekeeper in the scheme. “In Nigeria, however, what we see is a capitation of general and tertiary hospitals which are secondary and tertiary facilities. What you therefore get is that these secondary and tertiary facilities utilise NHIS funds as free booty.”
What must be done
A review of the NHIS operations and if possible, a reassessment of the enabling statutes for purposes of effecting some amendments is necessary in order to guarantee the scheme’s overall efficiency.
For instance, the legal instrument that established NHIS posits that health insurance is voluntary and such a stance may slow down the progress of the scheme because of its obvious limitations.
Countries that have made remarkable progress with NHIS around the world adopted the mandatory option and Nigeria stands to benefit more with a popular and tested programme than engaging in experimentation. Therefore, before the expansion of the scheme is vigorously pursued to get the country to an appreciable universal coverage height, this issue should be revisited.
Beyond that, priority attention must be given to enlightenment and persuasion of Nigerians to embrace the scheme. Despite being in operation for 12 years, millions of Nigerians especially in the informal sector know little or nothing about the scheme. To this end, the new leadership in NHIS should seek ways to deploying every available medium to create awareness about the activities of NHIS.
More importantly, authorities in NHIS should expedite action in reviewing the operations of the scheme along the line of accountability and effective control of resources. The strategy of re-accrediting all the HMOs reportedly being considered by the incumbent administration is commendable and should be sustained.
It is also important to engage state and local governments in order to fast track the expansion of the NHIS to every part of the country. In this regard Nigeria should borrow a leaf from Rwanda that has achieved over 90 per cent coverage despite facing intractable wars.
According to the Lancet, a global medical journal, Rwandan community based health insurance programme had within the first decade of its introduction, covered more than 90 per cent of the population and reduced out-of-pocket spending for health from 28 per cent to 12 per cent of total health expenditure, and increased service use to 1.8 per cent per year.
The journal explained that in achieving that feat Rwandan authorities engaged in a wealth categorisation programme which was originally developed as a basic community target scheme but was later modified to enrol the most vulnerable citizens into the national protection programmes.
The programme was then adapted to enable communities to assess the socio economic status of each citizen to provide a more progressive tiered premium collection system that includes full subsidies for members of the two poorest sub-categories.
In addition, a household cooperative savings mechanism which was developed by one rural district, has spread throughout Rwanda, with several districts reporting that up to 40 per cent of premiums are being fully pre-paid 3 months before the start of the next financial year.
It is on record in Rwanda that districts that engage the programme have reduced administrative costs and increased participation in decision making by village residents.
The operations of the NHIS in Nigeria as presently constituted requires re-tooling to urgently fast track the quest to bequeath a legacy of accessible good health care delivery to the citizenry.
And for a country that ranks 187th out of 190 countries – only ahead of Democratic Republic of Congo, Central African Republic and Myanmar according to the World Health Organisation’s ranking of the world health systems, the options available are not too many in getting the country out of the avoidable global attention.
Therefore, there is the need for an urgent repositioning of the scheme in order to safeguard the health of Nigerians. Beyond that, it is high time policy makers in the health sector began to look inwards with a view to adapting home grown mechanism that will invigorate the activities of NHIS and ensure wider penetration of the scheme to the remotest part of the country.