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Mandatory health insurance: Access to good health on the horizon

Health insurance is news every day because people are denied more coverage than they obtain and must struggle to pay medical expenses on their own. Research shows that four out of five people who go bankrupt these days in the developing world are pushed over the edge by mounting medical bills.

In countries such as Nigeria, such denials are due to preexisting conditions, or to experimental or unnecessary procedures. Some are much more controversial. However the bottom line is that most people do not seem the appreciate

When the National Health Insurance Scheme (NHIS) was established under Act 35 of 1999 by the Federal Government of Nigeria, its aim was to provide easy access to healthcare for all Nigerians at an affordable cost through various prepayment systems. The desire for a well performing health insurance scheme was premised on two major platforms – a reliable financing option and an acceptable legal framework. In theory, this arrangement works perfectly.

However, in practice, an efficient and equitable health financing system is only achievable when there are deliberate efforts to define a well articulated legal framework that not only provides a strong and institutionalized regulatory capacity but also makes it possible for adequate health resource mobilization, pooling and their efficient allocation. This was what the NHIS set out to achieve.

One of the recommendations of the newly amended Act is to make participation in the NHIS compulsory. Why make health insurance mandatory, one may be inclined to ask?

Health insurance may have to be mandatory in line with the new direction of thought of proponents of the health insurance bill awaiting approval of the National Assembly to meet the dream of every Nigerian to have full access to comprehensive healthcare services through a realistic social health insurance scheme. But while the idea of health insurance is well accepted, the idea of mandatory health insurance is a different story altogether.

Access to health insurance is a good measure for access to health services. While the NHIS has been able to enroll up to three percent of Nigerians under the formal sector health insurance programme, about one percent has also been covered in the private sector by the Health Maintenance Organisations. Low these figures are but a step towards the right direction of providing health insurance coverage for all Nigerians.

No doubt, there has not been remarkable improvement in national health indices if the MDGs are considered. In the view of Dr. Ben Anyene,  Chairman Board of Trustees of the Health Reform Foundation of Nigeria, HERFON, while the NHIS and managed care organisations in Nigeria have been able to provide health insurance cover to Nigerians though the expected goal of Universal coverage still seems distant. “Overall, because of the low coverage the potential of the scheme to impact positively on all the sectors of the economy remains unleashed.”

But in arguing for a mandatory participation, Executive Secretary of the NHIS, Malam Waziri Dogo-Mohammed notes:  “Under a revamped health care system, every employed Nigerian would be required to buy into health insurance and government would provide subsidies for the poor and indigent.”

The argument is that with other forms of insurance, such as house or car insurance, one could opt to go without owning a car or a house, and opt for available alternatives, but there are no such alternatives to good health and no one can afford not to have good health. So there may be no option with mandatory health insurance. Everyone would just have to get it.”

He argues that the Act establishing the NHIS makes social insurance optional. “Our experience shows that a number of important participants are not participating. The only way we can make it mandatory is to amend the Act. In the amended Act, NHIS is going to be made compulsory.

The name of the scheme will change. We have realised that the Act gave the scheme a very difficult name but by the time the Act is done with, we’ll have a better Act that will address most of the perculiarities of the NHIS.” He noted that while there is a scheme for students, vulnerable groups, or the indigent, the Act is for social health insurance, and cannot cover the private sector insurance unless the Act is changed.

“Vulnerable groups are not covered. We have the formal and informal insurance, but by the time you come and say you want to do the social health insurance, contribution is important. Somebody has to pay something. So for us to look at it as a mandatory exercise, the NHIS cannot be just a scheme.

It has to be like an agency that is going to be more or less like an authority so that it can be able to monitor the various schemes in the country and it is the Act that is going to make it mandatory.”

In many ways the argument for mandatory health insurance elicits hindsight. Essentially, the formal sector programme of the NHIS is designed to cover Nigerians in the formal sector employment, public and private, but the desire has been to extend coverage to other segments of society through series of programmes developed to cater for Nigerians outside the formal sector employment.

But there is a hitch in the guise of absence of a well-worded legal instrument required to define specific roles and responsibilities of stakeholders involved in the implementation.

The NHIS  was officially launched on 6th June 2005 and commencement of services to enrolees started in September 2005. Till date, over four million identity cards have been issued. So far 62 HMOs have been accredited and registered and more applications are being processed.

Presently, 5,949 healthcare providers, 24 banks, five insurance companies and three insurance brokers have also been accredited and registered. In the list of states that have so far shown their interests are; Rivers, FCT, Benue, Ekiti, Akwa Ibom while Cross River State has fully rolled in.

Although adjudged as one of the fastest growing social health insurance Schemes in the world,  aspects of healthcare delivery programmes aimed at ensuring good healthcare service delivery to all Nigerians as well as the protection of families from the financial hardship of huge medical bills, the scheme is still struggling to ensure equitable distribution of health facilities within the Federation and high standard of healthcare delivery to Nigerians.

Over the years, the NHIS has been confronted by series of challenges that have retarded its goals which if not corrected urgently, have potential to serve as an obstacle to plans to expand it to more beneficiaries. Top on the list of the obstacles is the NHIS enabling law (Act 35 of 1999). Perhaps its greatest failure, according to close observers is that it does not make participation in the scheme mandatory for employers with up to 10 and more employees.

Says Dogo-Mohammed: “The NHIS Act as currently worded and structured may not be able to provide leverage for the NHIS to achieve the desired result in pursuit of universal coverage for Nigerians with social health protection.

“Looking at the issue from a technical point of view, operation and sustenance of social health protection are dependent on the availability of strong and legal and institutional arrangements. Social health relies heavily on its pooling strength which can only be achieved where it is made compulsory for all the population or a defined segment of the population, hence the requirement of a comprehensive review. “

At the review summit held in Kano recently, stakeholders sought a middle point for provisions of the NHIS Act for its transformation into a bill.  “This is a major flaw that needs to be properly corrected,” noted the Executive Secretary. But there is more.

It has long been identified that one of the major weaknesses of the 1999 Constitution is that health is not properly articulated within its provisions. According to Dogo-Mohammed, “This creates its own problems. Our experience has shown that other tiers of government have not been as committed as the central government as it relates to the NHIS.”

Another factor is that the task of providing coverage for the informal sector using the community-based health insurance to mobilise adequate resources for the healthcare of its participants is generally poor. The prevalent levels of poverty within the group cannot be overlooked.

As a way of enhancing performance, Dogo-Mohammed recommends targeted subsidy to finance gaps, pay for vulnerable groups and the poorest of the poor in society and provide stewardship for the inherent poor technical capacities in management.

But the scheme does have its limits. As a social health insurance, it does not cover everything, for instance disorders such as cancer, diabetes or heart surgery are not covered. The argument is that social health insurance looks at the burden of disease in the society and tries to capture 80-90 percent of the burden.

“So by the time you try to cover disorders such as cancer, diabetes or heart surgery, it would mean you are already susceptible to those conditions. The basis is that if Nigerians want cover for everything, they should be ready to pay more.

This scheme is contributory. It is not free. As of today, six years after, no employee of the Federal government has started contributing, yet there is agitation for  increase in the benefit package. If you want everything, you have to pay more.”

Currently, no beneficiary in the formal sector is contributing. “Federal government is standing as cover for us and paying 10 percent on behalf of employees, that is the agreement. Meanwhile, labour on behalf of employees says too many deductions are being carried out in their earnings, so  the need to expand benefit cover of diseases said we should carry them along to see where more resources are required.”

Other deficiencies remain, but can it really be said that the NHIS is totally committed to securing universal coverage and access to adequate and affordable healthcare in order to improve the health status of Nigerians, especially for those participating in the various programmes/products of the Scheme?

Many stakeholders believe so. They point to the general poor state of the nation’s health services and the excessive dependence and pressure on Government provided health facilities, and that with the dwindling funding of healthcare in the face of rising cost, the Scheme is designed to facilitate fair financing of health care costs through pooling and judicious utilization of financial risk protection and cost-burden sharing for people, against high cost of health care through institution of prepaid mechanism, prior to their falling ill. This of course is in addition to the provision of regulatory oversight on Health Maintenance Organizations (HMOs) and other players in Healthcare delivery.


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