There has been a renewed clamour to review the jagged edges of the Act establishing the National Health Insurance Scheme (NHIS). Kingsley Nwezeh looks at the contentious parts of that legal provision the arguments by the Minister of Health, Prof. Isaac Adewole, and other stakeholders on the need to review the law
Recently the Minister of Health, Prof. Isaac Adewole, raised the issue that the Act establishing the National Health Insurance Scheme required a comprehensive review in order to make it work more efficiently and effectively.
The NHIS, established to provide health insurance coverage for Nigeria’s teeming population, has performed below expectation, providing less than five percent coverage of the nation since its inception 16 years ago.
Besides, the agency has been embroiled in leadership crisis since inception with every executive secretary, except one, since inception, accused of one corrupt act or the other, the most recent being the face-off between the suspended Executive Secretary, Prof. Usman Yusuf, and the NHIS Council over allegations of financial impropriety levelled against the former.
“The Act made insurance voluntary and that is why we are supporting National Assembly to repeal the Act and put in place a comprehensive package.
“Let it be comprehensive because it cannot be voluntary. There is need for review of the Act and it is ongoing.
“I can tell you today that no Executive Secretary of NHIS has completed a full term in office without being sacked or suspended, apart from Mohammed Dogo, the pioneer ES, so it’s not just about this administration,” he said.
“We are asking the presidential panel to take a more holistic look at the NHIS, to review the Act of the scheme. The act seems to have given so much power to the governing board.
“The governing council, by that Act, was given the power to do whatever is necessary to keep the scheme running. If the council now thinks it is important to do anything to keep the scheme running, nobody can say no,” the minister said.
A closer look at the Act shows that it gave overriding powers to the governing council. For instance, Part II, Section 7 puts the council in charge of the general management of the scheme.
“The council shall have power to manage the scheme in accordance with the provisions of this Act;determine the overall policies of the scheme, including the financial and operative procedures of the scheme; ensure the effective implementation of the policies and procedures of the scheme; assess, from time to time, the research, consultancy and training programmes relative to the scheme.
The council is also vested with the powers to “arrange for the financial and medical audit of the Zonal Health Insurance Offices established under section 21 of this Act; set guidelines for effective co-operation with other organisations to promote the objectives of the scheme; coordinating quarterly returns from the zonal health insurance offices.
It is also charged with “ensuring public awareness about the scheme; coordinating manpower training under the scheme; carry out such other activities as are necessary and expedient for the purpose of achieving the objectives of the scheme as set out in this Act.”
In terms of other management functions, the act states that the council shall “appoint for the scheme, such number of directors and other employees as may, in the opinion of the council, be required to assist the council in the discharge of any of its functions under this Act; and pay to persons so appointed such remuneration (including allowances) as the council may, after consultation with the Federal Civil Service Commission, determine.”
Part III, Section 9 of the Act holds that, ”The Council shall appoint for the Scheme, a licensed actuary on such terms and conditions of service as the council may, from time to time, determine.
“The actuary shall review the scheme and evaluate it actuarially, including the rates of contributions payable under the scheme and make appropriate recommendations to the council.
“If, having regard to the review and evaluation carried out by the actuary under subsection (2) of this section, the council considers that the rates of contributions have not retained their value in relation to the general level of earning obtaining in Nigeria, the council may modify the rates to the extent considered appropriate and bring the new rates to the notice of the persons affected by the modification.”
The Healthcare Providers Association of Nigeria (HCPAN) has also weighed in favour of a review of the Act with its recent call on the National Assembly to repeal the NHIS Act.
National President of the Association, Umar Sanda, had decried what he described as the “static nature” of the scheme.
He said the situation had affected earlier decisions of the states to join the scheme, regretting that it had been relegated.
“We have not seen enrollees added to the list and providers are feeling the pinch”, he said.
He said universal health coverage could only be achieved when NHIS is made compulsory.
“The law setting up the act is a problem. As long as this 8th Assembly does not pass the new law on health insurance, we will not move any step further.
“The law has passed the second reading. It is more than eight months now, we have not heard anything about it. We believe that the only way of financing health is by health insurance, the government cannot do it alone,“ he said.
Sanda argues that the law erodes both providers and the rights of enrollees while giving more powers to regulators.
“There are so many things wrong about the law. “How can regulators keep the premium and then disburse the money? That is why you have friction between the health managers and the regulators and that is why you have providers not being paid as and when due.
The pre-paid programme is now totally a post-prepaid programme,” he said.
In his submission, the National President of the Pharmaceutical Society of Nigeria, PSN, Pharm. Ahmed Yakasai, NHIS remained the gateway to achieve universal healthcare coverage.
“There is the need for government to review the NHIS Act as this would allow all Nigerians to enroll in NHIS. Now, for instance, many of the enrollees go to private hospitals because the Act has not been reviewed.
“I can assure you by the time the Act would be reviewed, every Nigerian would be going to general hospitals without paying.
We are saying let us have a fee for service in NHIS,” he argued.
On his part, President, Association of General Medical Private Practitioners of Nigeria, AGPMPN, Dr Iyke Odo, said a universal health coverage would make it possible for everybody to be registered and covered by health insurance and if it is made compulsory through rule of law, it will bring back honesty, disciplined leadership. He said the law establishing the scheme had clearly defined the role of all stakeholders.
“We need universal coverage where every provider will be guaranteed of critical mass, and adequate number of enrollees,” he said.
On his part, President of the Nigerian Medical Association (NMA), Dr. Dayo Faduyile, stressed the imperative of repealing the Act to enhance its efficiency and effectiveness.
“One thing we are going to do is to go to the National Assembly to ensure that the Act that set up the National Health Insurance Scheme is reviewed and amended.
“The Act made it optional and when it is optional it is not enforceable. We will want it to be mandatory. It is at this point that we will have many people coming to join the scheme.
“What we are advocating is that the NHIS should not be the regulator and the effector at the same time.
“We should have a regulator and have other people who will key in and the money will be better utilised.
“We need a constant review of every law. Since the formulation of this law, there has not been any time they sat down to discuss the rate they pay.
“The NHIS is just for the federal civil servants because it has not been reviewed to be expanded.
“Federal civil servants have less than 10 per cent of the population of the nation. This has significantly kept us where we are today. NHIS has not been able to cover a large percentage,” he said.
Most stakeholders are agreed that the voluntary nature of participation in the scheme is the reason the health insurance coverage is stalled, unable to sufficiently cover the population.
There is also a united view that when it is compulsory, the coverage would be comprehensive.
“That is why we say the Act needs to be revised and be more specific. If you look closely, it is as if the council does almost everything there.
‘The Act is one of the major issues with the scheme. Why NHIS has not covered majority of Nigerians, is because it is voluntary.”
“When it is voluntary, it makes people not take it seriously. Our disposition- as Nigerians, we don’t take our health critical. We don’t even treat our body the way we treat our car. When we wake up in the morning, you have a car, you clean it up, you test the engine oil, you test the water level etc. Many people don’t treat their body as well as they treat their cars.
“When it comes to health, nobody wants to pay for health. We all want it free and that is why, for us to make it free, somebody has to pay for it. In the UK, the health insurance is there, but it’s being funded, essentially, by taxation.
“What we need to look at in NHIS is how do we put more money in health, put more resources together, to take care of everybody and ensure maximum coverage,” the Health Minister, Prof. Adewole, posited.
The attempt to review the Act started in 2004 but stalled for inexplicable reasons. A second attempt commenced in 2014 following an amendment bill introduced by Senator Lanre Tejuosho.
The bill was read the second time in the Senate eight months ago and has since lost steam. With general election around the corner, a review of the Act could only take place when a new National Assembly is inaugurated.