With the successful signing of the National Health Insurance Act (NHIAA) 17, which gave birth to National Health Insurance Authority, health insurance experts said the coast is now clear for inclusive implementation of the initiative, writes Ebere Nwoji.
On May 19, 2022, the federal government achieved a major breakthrough towards realising its tall dream of riding on its 22 year old National Health Insurance Scheme (NHIS) to achieve the universal Health Insurance initiative in Nigeria.
The government did this through the signing of mandatory health insurance bill into law by the National Assembly to give birth to the National Health Insurance Act (NHIAACT) 17.
The signing of the National Health Insurance Act 17 seized the existence of National Health Insurance Scheme (NHIS) and changed the nomenclature of the regulator, the National Health Insurance Scheme (NHIS) to National Health Insurance Authority (NHIA), headed by Professor Nasir Mohammed Sambo, as the Director General.
Situation before now
Prior to this change, it was difficult to promote NHIS as effective means of delivering health care services to Nigerians since the NHIS was signed into law in 1999 through the NHIS Act 1999.
The agency was established to address the problem of poor state of health care services delivery in Nigeria.
The NHIS was given the core mandate of ensuring that every Nigerian has access to qualitative and affordable health care services. The overall goal was to achieve the universal Health Care initiative of the United Nations.
The NHIS, which was established by decree 35 of 1999, was signed by General Abdulsalam Abubakar in May 1999. Under the democratic dispensation, the National Assembly adopted and codified the decree as NHIS CAP N42LFN2004.
Both military and democratic regimes in Nigeria have since then been pushing to sell the idea of health insurance scheme to Nigerians but their efforts could not record much success with the result that 22 years down the line, most Nigerians especially private sector workers detested it.
Although initially, the prime target of the NHIS was a public sector worker few years back it was extended to private sector workers and the self employed.
Legislative problem
A critical examination of the workings of the scheme and the laws establishing it reveals that the NHIS was undermined by constitutional provisions on health coupled with voluntary disposition to health insurance by many Nigerians.
Legislation wise, in specific terms, section 16 sub-section 1 of the NHIS Act which states that “an employer who has minimum of 10 employees may together with every employee in his employment contribute to the scheme is not obligatory.
In his analysis of the NHIS Act, the General Manager, NHIS now NHIA Olufemi Akigbade, said the clause “may“ in Sub section 1 of NHIS 16 culminated in the reluctance of states to collaborate with the NHIS to achieve its mandate, According to him, this is because the clause “may“ instead of “shall” stated by the legislation made it optional so that contributors into the scheme have a choice to participate or not to participate in the NHIS scheme.
He said with this particular Act, NHIS was perceived to be a weak legal document and an obvious clog in the wheel of progress towards achieving UHC.
According to Akingbade, against this backdrop, it became obvious that there is need for a revised NHIS Act, a height which according to him different CEOs of NHIS tried to achieve but could not until three years back when Sambo took over the leadership baton of the NHIS.
He said Sambo pursued the change of the legislation with vigor and achieved success in May this year, by changing the clause “may” in the section 16 of the NHIS to “shall” thereby making it an all inclusive policy. He said credit to this goes to Sambo.
NHIA administration plans
At the SEMPER FIDELIS Award organised in his honor by the Health Care Providers Association of Nigeria in Lagos recently, Sambo said his administration would ensure that with the new legislation, Nigerians of all classes, including the vulnerable would have easy access to quality health care service delivery through the National Health Insurance Scheme.
He said that to ensure effective implementation of the scheme, the federal government would spend a whooping N1.4 trillion for the health insurance premium of about 83million Nigerians who fall within the vulnerable group citizens of the country.
Sambo who stated this during the award ceremony said out of the above figure, federal government’s annual budgetary provisions for health care needs of Nigerians accounts for only 9.6 percent of the figure.
He said the vulnerable citizens constitute about 40 percent of the Nigerian population whom federal government needs to pay for their health insurance bills to deepen penetration of the National Health Insurance Scheme.
This by interpretation means that the remaining 60 percent of the population outside the vulnerable group has no provision for their health care needs annually and will need to key into the NHIS to get their health care services.
Sambo said the new National Health Insurance Authority instituted by government in May 2022 to replace the hitherto National Health Insurance Scheme through the change of some clauses in section 16 of the National Health Insurance Act, is working assiduously to achieve the Universal Health Insurance initiative of the United Nations even before the year 2030 target.
He said the problem of effective implementation of the scheme over the years has been the regulation, which failed to make it compulsory for the states to be part of the scheme.
He said with the successful change in the regulation, which has made it all-inclusive scheme its effective implementation nationwide is sure.
He said the National health insurance scheme if fully implemented would help Nigeria to key in and achieve the United Nations Universal health initiative by the year 2030.
“We want to achieve universal health initiative of the UN before the deadline in 2030 by this singular act by the President the law has made it clear, we are promoter, regulator, integrator what we are after now is how to operationally use the law so that all issues that have to do with population will now come in our operational guidelines and what are the necessary structure to ensure that regulation is done. On top of it, we have worked assiduously under our Digital Transformation framework whereby everything can be IT driven. These are structures that have been put in place so that by the time the guideline is very clear in line with the stipulation of the law, we are certain that we will have a very robust mechanism to control effective regulation”, he stated.
According to Sambo, government is ready to pay for about 83 million Nigerians that are vulnerable but that for those who can afford to pay for themselves, that is those that are workers and are self employed, will pay for themselves to ensure that the National health insurance scheme is all inclusive.
He described the change in the clause in section 16 of the NHIS and the replacement of the NHIS with NHIA as paradigm shift to achieving UHC.
“The birth of the NHIA is a critical aspect of the needed reform in health financing in Nigeria The out of –pocket expenditure for Nigeria would drop with the increases state of health insurance subscriber base coverage of vulnerable population. There will be full implementation of the demand side of the BHCPF of the National Health Act 2014.
He said the NHIA would lay the foundation for building strong system that would regulate HCPs, HMOs and TPA and MHAs among others.
According to him, the new Act now empowers the NHIA to ensure provision of mandatory health insurance for all Nigerians.
“The new NHI Act will improve quality of care via increasing health care facility revenue”, he stated.
He described the new NHIA as a new resource mobilisation for the health sector that has been bedeviled by low budgetary spending adding that it would provide the needed boost for a growing subscription and the needed funding gap to reach the goal of reducing out of pocket expenditure.
“You see, insurance, whether health or whatever, is a risk-pooling business where resources are pooled together in case a member of that pool has any risk so the total money will be used to service the people who need the service at that particular time. In health insurance, it has been noticed that not up to 20 per cent of the people that are insured will actually go to the hospital at the same time to take service and it is the money of the remaining 80 per cent people that will be used for these 20 per cent and so if you contribute N15, 000 per annum, you know that N15, 000 per annum cannot take care of you. For example, you need to have surgery, you have a child to deliver or major illnesses that requires treatment that you are admitted and N15000 cannot do that and you can do that more than once a year.
The workings of scheme
Speaking on the workings of the health insurance scheme the Programme Manager, National Health Insurance Scheme, Federal Capital Territory Abuja, Dr Ahmed Dan-Fulani, the health insurance scheme has pooling effect advantage.
According to him, it is because of that pooling effect of all the money paid that we can now have enough money to take care of you when you are sick when you just pay only N15, 000 as premium. He was optimistic that when many people understand the fact that it is a risk pooling business that entails other people insured sharing on your risk so they will understand it more and then log onto it.
“Besides, everywhere in the world where you see them having a standard health care system, it is basically health insurance, there is no government that gives free health and there is no citizen that can pay out of pocket for all the health care he or she needs so the necessary thing to be done by any country is Social Health Insurance Scheme, “he said.
Private health insurance organisations
THISDAY notes that though initially, state governments, private sector workers and self employed were disenchanted with the scheme preferring to get their healthcare needs through out of pocket payment in recent times, these category of workers have willingly embraced various private sector driven health insurance scheme provided by Health Management Organisations (HMOs) and many insurance firms are now floating their various HMOs.
For instance, Leadway Assurance has its HMO tagged, AXA Mansard, Royal Exchange Assurance have their HMOs. They attach their premium payment to their various insurance product.
During the launch of its HMO Leadway Health Ltd, in August last year, Chief Executive officer of Leadway Health, Dr Tokumbo Alli said that the introduction of Leadway health would serve as a disruption and an exceptional redefinition of delivery of reliable and affordable health care to the public.
He said out of estimated 200 million Population of Nigeria more than 190 million is paying out of pocket to get their healthcare services.
He said this is abnormal as he urged Nigerians to shun out of pocket expenses for their healthcare needs and embrace earth insurance services
