April 18, 2024

NHIA: Nigerians wait for promised gains despite mandatory enrolment

By Chioma Obinna

When the administration of former President Mohammadu Buhari on May 19 signed into law the National Health Insurance Authority Bill (2022), it birthed a new hope in the minds of Nigerians and major stakeholders in the health sector with the belief that it would improve services and create access to affordable health leading to Universal Health Coverage, UHC, in line with the united nations Sustainable Development Goals, SGDs by 2030.

The Bill signed into law for the records repealed the previous NHIS legislation. The Federal government claimed that the action was strictly to improve access to quality and affordable healthcare for all Nigerians.

The Act made health insurance mandatory for every Nigerian and legal resident. It was also to further promote, regulate and integrate health insurance schemes nationwide, and harness private sector participation in the provision of health care services.

It also provides that all indigent citizens enjoy free healthcare funded by federal, state and local governments and their partners.

Buhari in signing the Bill into law expressed confidence that the new law will bring hope to about 83 million poor Nigerians who pay out of pocket for their health needs.

But months after, the law is yet to be fully implemented. These poor Nigerians are yet to reap the real benefits of the law.

Today, with the high cost of drugs and medical consumables occasioned by the free fall of the Naira, healthcare has become more unaffordable for most Nigerians and the few, who can afford it, still pay out-of -pocket while millions are denied access or left with alternative care that may ruin their lives.

Findings by Good Health Weekly showed that the situation has deprived millions of Nigerians access to healthcare, and increase patronage to unregulated herbal concoctions and self-medication, leading to increasing heart-related diseases, kidney failure and skyrocketed hospital bills due to preventable complications.

A case in point is Mrs Adeline Nkwo, a mother of two.  She never attended antenatal in a hospital until she was due for delivery.  Like her first two children, Adeline was confident that her delivery would be successful.  Unfortunately, the situation took a different turn as the Traditional Birth Attendants, TBAs, who delivered her of the first two children, could not handle the delivery and she was referred to one of the hospitals in Oyo. Sadly, her husband, a Keke driver could not pay the initial deposit required for her treatment. It took two days for the family to be able to raise half of the money. Unfortunately, it was late and the baby died in her womb which led to other complications.

Her case is just one out of the thousands of Nigerians who are not covered under any health insurance. 

Findings show that the informal sector constitutes a significant portion of Nigeria’s workforce, many individuals in this sector lack access to health insurance coverage due to challenges of limited awareness, affordability concerns, and administrative barriers.

To ensure that this group is captured, most states have established their health Insurance Schemes to complement the NHIA and extend coverage to residents. These state-level schemes vary in scope, coverage, and implementation effectiveness, impacting overall progress towards universal health coverage, UHC.

State Governments commit to dedicate a percentage of their consolidated revenue to the scheme to fund premiums for the poor and vulnerable in the state. Also, each state is expected to provide the minimum package of basic essential health services as the benefit package. However, these benefits are yet to take effect in many states.   Citizens in the various states still pay out of pocket apparently due to lack of awareness.

Although, states like Lagos and Oyo and a few others have initiated state wide health insurance, residents are yet to embrace it.

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A report tagged: “Out-of-Pocket spending as a share of health expenditure in Nigeria from 2019 to 2022, Nigeria’s out-of-pocket expenditure was put at 76.2 per cent in 2022, up from 71.9 per cent in 2021.

Also, a recent online poll showed that only 17 per cent of Nigerian adults have access to health insurance while millions are uninsured.

Data from the Nigeria 2021 Multiple Indicator Cluster Survey, the percentage of the population covered by health insurance has been steadily increasing over the years but significant gaps  exist, with a substantial portion of the population, especially the vulnerable, remaining uninsured.  Statistics from the Nigeria Bureau of Statistics under the key messages from the report showed that only 3 per cent of individuals are health insured.

For instance, in the South West region of the country, Lagos leads with 8 per cent of children under age 5 and women under age 15 and 49 covered, while 9 per cent of children under 5 to 17 are also covered.

Oyo dangles between 1 per cent and 2 per cent for all ages, Oyo between 3 and 4 per cent, Osun is between 2 and 5 per cent, Ondo 8 per cent for under 5 children and women and older children 2 per cent, Ekiti 1 per cent and Edo 8 per cent for children under 5 and 17 while women and under 5 are 2 per cent.

As of December 2023, the Executive Director of the Lagos State Health Management Agency, LASHMA, Dr Emmanuella Zamba, about 923,000 individuals have been enrolled in the scheme, of which 334,000 are vulnerables.  And there were plans by the Agency to cover an additional 200 to 300,000 people.

Also in Oyo state, a total of 190,968 people have been enrolled while the formal sector has enrolled 104,533, and the informal sector has 86,435 enrollees, hence, the state agency is targeting 500,000 vulnerable enrollees this year, according to the Executive Director, Dr Sola Akande.

The story is the same in other regions of the country. Some states are yet to fully implement the mandatory scheme even though it would enable them to have access to funds from the Basic Health Care Provision Fund, where the federal government will provide money to meet the health insurance needs of the vulnerable.

In the views of a UNICEF Health Specialist, Dr. Ijeoma Agbo, health insurance is a gateway to achieving universal health coverage, UHC, as it is critical to attaining SDG 3 which focuses on ensuring healthy lives and promoting the well-being of all.

Agbo who noted that the UHC service coverage index improved from a global average of 45 out of 100 in 2000 to 64 in 2015 and 67 in 2019, said the report noted that almost 1 billion people spent more than 10 per cent of their household budget on out-of-pocket health expenses in 2021, and more than half a billion were pushed into extreme poverty due to these out-of-pocket payments.

She said to accelerate progress towards UHC in Nigeria, concerted efforts were needed to address systemic challenges and strengthen health systems.

Agbo said that achieving UHC requires a multi-sectoral and collaborative approach involving government agencies, healthcare providers, civil society organisations, the private sector, communities and media.

She said strengthening regulatory frameworks, enhancing funding mechanisms, including increased investment in healthcare infrastructure and improving the quality and accessibility of healthcare services can contribute to achieving UHC in Nigeria.

She further stressed the need for the inclusion of essential health services in the benefit package of health insurance schemes including nutrition services.

“Enhancing community engagement and awareness about the benefits of health insurance and addressing barriers to enrolment, such as affordability, awareness, and trust in insurance systems, is essential for expanding health insurance coverage,” she said.

She added that by working together, stakeholders can overcome barriers, leverage resources, and ensure that all Nigerians have access to the healthcare services they need without financial hardship.

Benefits of health insurance

Speaking on the benefits of Health Insurance in achieving UHC, Agbo said health insurance provides financial protection thereby reducing the burden of out-of-pocket expenses on individuals and families.

She said it can prevent catastrophic health expenditures that can push households into poverty, ensuring access to healthcare services without financial hardship.

“It enhances access to a wider range of healthcare services, including preventive, curative, and rehabilitative services. Individuals with health insurance are more likely to seek timely medical care, leading to early detection and treatment of illnesses, ultimately improving health outcomes. Equity and Inclusivity: Facilitates equitable distribution of healthcare resources, and promotes equity by ensuring that healthcare services are accessible to all individuals, irrespective of their socio-economic status or geographical location.

“It reduces disparities in access to healthcare, particularly benefiting vulnerable and marginalized populations, thus contributing to the goal of leaving no one behind.

“It also facilitates efficient allocation of healthcare resources by pooling funds from a large population and distributing them based on healthcare needs. It promotes the rational use of resources, leading to cost-effective delivery of healthcare services and better health outcomes for the entire population.

“A robust health insurance system contributes to the sustainability of the healthcare system by providing a stable source of funding for healthcare delivery.  It reduces reliance on unpredictable and volatile sources of financing, ensuring the continuous provision of essential health services to meet the evolving healthcare needs of the population.”

On challenges and barriers, Agbo stated that despite progress, challenges persist in achieving UHC in Nigeria, including inadequate funding, and limited awareness about health insurance and its benefits.

She also identified infrastructural gaps in healthcare delivery, and socio-cultural factors, such as mistrust in insurance systems and preference for traditional healing practices, as factors posing barriers to the uptake of health insurance in Nigeria.

In the views of the Executive Secretary of Oyo State Health Insurance Agency, OYSHIA, Dr Sola Akande at a two-day media dialogue tagged “Changing the Narrative on Child Mortality through Health Insurance” organised by OYSHIA and UNICEF, health insurance is the most viable part of healthcare financing that any country should adopt to ensure safe mothers, safe babies, healthy, happy, and prosperous society.

Akande who said the Oyo State government was determined to change the narratives in the state; said health insurance was a sure way to reduce poverty and untimely deaths in Nigeria.