Editor’s Note: Dr. Cheluchi Onyemelukwe is Lead Consultant at Health Ethics and Law Consulting, a health law and policy firm, which provides cutting edge legal and policy advisory on the life sciences, health, gender, and other development matters. In this week’s Thought Leadership piece she deftly takes apart the current state of the NHIS and reflects on what it will take for the new Executive Secretary to effectively rebuild the battered organisation. Her book, Health Research Governance in Africa: Law, Ethics and Regulation is forthcoming from Routledge.
Recently, the National Health Insurance Scheme has been in the news with the new CEO/Executive Secretary, Prof Yusuf Usman, making statements regarding the rot in the system and the need to ensure integrity and a fraud-free NHIS. We applaud his courage in speaking out on the challenges of the Scheme, and look forward to the concrete steps he plans to take to change the system.
An advocacy group recently sought my opinion on the possibilities of bringing legal action under the free health laws of some states. It is not inconceivable that some persons, groups of persons, or advocacy groups may at some point bring legal action against the NHIS on the basis of its mandate. Some analyses of the Scheme have identified several challenges. These range from a conflation of the regulatory functions, payer, risk-bearer, and policymaker functions, the non-mandatory status of the Scheme, to the lack of awareness, and more recently, the inability of the Agency to provide data on the breadth of coverage.
It is clear that the goal of universal health coverage (UHC) which all countries should aim towards will not be attained without addressing the problems of the NHIS. I would like to emphasise the issues that must be dealt with, but also to make concrete recommendations of practical, feasible steps that can put the Agency in a better place to achieve its mandate.
Any repositioning of the NHIS would have to take into cognisance its objectives and its powers to bring into reality such objectives as articulated in the enabling statute which established the NHIS – the National Health Insurance Act, 1999. The most important of these objectives under Section 5 of the Act is to ensure that every Nigerian has access to good health care services.
It is clear, even from mere anecdotal evidence that none of the goals under that section are anywhere close to being accomplished. Few Nigerians have access to good health services. Many, if not most of all families continue to face financial catastrophe in the unfortunate event of ill health. Indeed, it is not even clear how many persons are currently covered by the NHIS. Much of the data that is available appears to be mere speculation – the current magic number appears to be ‘less than 10 per cent’ with an adding on of figures and percentages with each further year that the NHIS exists. Issues of planning, transparency, and inadequacy of coverage thus remain continuing challenges.
The quality of available services, for those who have access to it, is debatable. While the NHIS conducts quality assessments and clinical audits from time to time, there is little evidence that patient satisfaction is increasing or that outcomes meet best practice standards.
The question that logically follows then is: How can the NHIS be repositioned to provide effective services?
To reposition the NHIS, several matters need to be attended to as a matter of urgency:
- Be Clear about the Goal: The Executive Secretary must understand the mandate of the NHIS as laid out under the law. This may sound simplistic but it is not. There should be clear answers to the questions surrounding the reason the NHIS was created, which as I have pointed out is to provide all Nigerians with good health services without undue financial hardship. There should be an identification of the steps that have been taken in the past, for instance, whether capitation truly works in our context or whether it lead to fraud, and a clear understanding of what needs to be done now.
- Take a Broader View of Needed Reforms: Reforms should be based on the objectives of the Scheme.. Thus, for example, merely knowing how many Nigerians are covered by the NHIS is not sufficient if the Act states as one if its objectives the ensuring of health services to all How many Nigerians have insurance of any kind – community based health insurance, private health insurance etc.? To move to a more efficient system, technology is key. An important step would be to identify the technological challenges of the NHIS in obtaining this data, or analyse why these technologies have not been optimally used. This type of reform will also encourage transparency, which in turn encourages accountability. Accountability helps the Agency, researchers, and the Nigerian people whom it serves gauge how well it is doing and better understand where solutions may still be needed.
- Address the Informal Sector: The informal sector continues to be a challenge, not least because of the lack of empirical information and inadequate sensitisation, amongst other contextual problems. Re-thinking some of the programs of the NHIS may be helpful in this regard. The Mobile Scheme, which was promoted over a year ago, seemed to be promising in design. There is no clear sense of why it was discontinued – the speculations are that there were disagreements with the telecom operators. However, this remains an easy way to provide information on, and access to, health insurance in a relatively painless manner. The limited effectiveness of community-based health insurance schemes (CBHIS), whether under the NHIS or under donor-funded or state-directed programs, and the need for a phased approach with sufficient funding have been noted elsewhere. It would be worth the effort for the NHIS to do a proper review of the studies that have analysed CBHIS Schemes and learn and apply any lessons learned.
- State Health Insurance Schemes: The National Council on Health last year approved State-Supported Health Insurance Schemes. It is hoped that these will help draw more people into health insurance coverage, thereby limiting financial catastrophes during illness and ultimately increasing UHC. Recognising the residual nature of health in Nigeria’s constitutional arrangements, the active participation of states is a welcome development. Several states have adopted these schemes, and have passed legislation to, amongst other things, make participation in these schemes mandatory. It remains to be seen how effective these schemes will be.The NHIS, however, needs to be clear about its role in these Schemes. If all goes well, there may end up being thirty seven pools. At first glance, this may appear problematic. But if it means that almost all Nigerians have coverage or access to coverage, this would be a good thing. The NHIS must be clear about the long term implications of this and its continued role in ensuring coverage for all Nigerians.From a legal perspective, the NHIS also needs to review its legislation to ensure that there is a proper devolution of powers to States. It is important to ensure that standards are the same or higher across board. For example, right now the NHIS is not mandatory whereas these state schemes are. Some states retain their free health laws on the books, although these laws have not been effective in providing quality services that are truly free. Other states do not prioritise health care services, leaving users with severe out of pocket expenses.
- Reform its Enabling Law: The matter of reforming the establishing Act, the National Health Insurance Act of 1999, has been in the works for a while now. Some ideas have been discussed over the years, including the need to make the Scheme mandatory in order to encourage more pooling and more coverage. With the State Schemes mentioned above choosing a mandatory approach, this need is even more imperative to ensure non-fragmentation of coverage throughout the country. It must also be clear what mandatory means, the modalities and how it will be accomplished – by insisting everyone has some form of insurance or compelling persons to purchase coverage from the NHIS or the State Schemes with top-ups provided by private health insurers etc.An impartial review of the stakeholders and the key roles that they should play, given the experience of the past decade or so, would also be necessary. This would likely result in some amendments to the relationships between the NHIS and other stakeholders including the Health Maintenance Organisations (HMOs). This would be a good time to clarify the role that the NHIS should ideally play and ensure that the amended legislation reflects this. Is the Agency primarily to be a pooler, a regulator or both? What are the advantages or disadvantages of each approach? Also, the existence of the new State Schemes needs to be reflected in the new legislation and the role of NHIS in this regard would need to be clarified.
- Regulate Effectively: One of the major areas of concern has been with the regulation of HMOs. There continues to be a perception that HMOs are freeloaders who act as expensive middlemen between the Scheme and the users of the Scheme and bear little or no risk. Providers complain about lack of payments or delayed payments. The NHIS has, in the past, sought to address some of these issues through stricter accreditation processes and outright removal of accreditation from NHIS. Yet the perception persists that the steps taken are insufficient. Given practical and contemporary realities, some would argue that HMOs are here to stay. Indeed, some of the State legislation on health insurance clearly allow participation by HMOs as third party administrators. Beyond that and on a more practical note, the question of whether or not any other bodies, including the NHIS, has the capacity to undertake the current functions of the NHIS remains germane. While that discussion continues, it is incumbent on the NHIS to take its regulatory role seriously. It would take a great deal of integrity and courage to effectively regulate the service provided by HMOs. Such integrity and courage must now be summoned by the Executive Secretary with the support of his staff.
- Implement the Basic Minimum Package: The National Health Act provides that every Nigerian is entitled to a basic minimum package of care. The NHIS is responsible for ensuring that this is provided through primary and secondary facilities. A set of guidelines was approved for the disbursement of the Basic Health Care Provision Fund as provided under the National Health Act by the National Council on Health in September 2016. The guidelines contain several accountability mechanisms for ensuring that the Fund is utilised to ensure results. The NHIS must be willing to do its part, alongside other key stakeholders, without losing focus of its larger mandate as contained in the NHIS Act.
This is obviously not an exhaustive list and some of the issues are almost universally acknowledged with divergences in how best to approach them. This piece further proposes some ideas, including ideas on the improvement of the legal framework. The issues remain outstanding and require effective resolutions for the NHIS to make progress, and for all Nigerians to enjoy universal health coverage. The statements of the Executive Secretary are a positive step in the right direction. But now we await action and ask: What next?