Lost in the Debate: Five questions no one is asking about the National Health Insurance Scheme in Nigeria

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As the debate rages on regarding the return of the Executive Secretary of the National Health Insurance Scheme (NHIS), after his suspension by the Honourable Minister of Health, the discussion is focused on the political intrigues rather than the heart of the issue. Much commentary has been written, breakfast shows have debated his return, yet few have focused on the big issue. How do we as a society ensure that health care is available to all that need it at the point of care, and at a cost that does not wreck them financially?

There seems to be  no better mix for conversation in Nigeria than allegations of corruption, especially when mixed with conspiracy theories and power tussles, and while these have their import, we must not be distracted from what matters most – access to quality and affordable healthcare in Nigeria.

There is hardly any Nigerian today who has not contributed huge sums of money to the management of a catastrophic health event for herself/himself, for family or friends. While this has become normal in our country,  this is not normal for the 21st century. How do we get out of this? How do we create a more equitable health sector? Who will be Nigeria’s Bevan (Founder of the UK’s tax funded health system) or our Bismarck (Founder of the post war’s social health insurance system in Germany and Western Europe) ?

Photo source: www.jemmapeacock.org

As we enter a new election cycle, we must focus on the questions that matter the most to Nigerians, so that we can compel our politicians to focus their minds on the interventions that matter.

Below is our list of the five most important questions we need to ask on healthcare financing in Nigeria. There may be others that you think are important – we urge you to put them on the table. Join us to put these questions front and centre of the upcoming election debates and maybe, collectively, we can move away from the mundane debates to those that matter most for Nigerians.

1. Are we really committed to health insurance as our approach to healthcare financing?

 Health insurance sounds very simple on paper, but it is actually a very complex approach and requires a dogged determination to put in place the necessary steps for it to work. The most important of these is the size of the risk pool. This model will only be an efficient way of financing healthcare if a large enough size of the target population participates in the pool. This can only work using either regulations or enforcement to ensure mass enrolment into the pool. It simply does not work as a “voluntary” scheme, as we end up with only those most at risk of getting ill. If we plan to continue focusing on health insurance as our primary model for health care financing, then now is the time to take some hard decisions as a country.

Photo source: @PenComNig

2.  If public-funding-supported health insurance is the system we wish to pursue, when will the NHIS provide a simple transparent system to answer basic questions to justify its existence?

The NHIS is a government agency and in that role, transparency in its activities is expected. Yet, getting accurate information from the parastatal has proven to be difficult. For instance, it is still almost impossible to get an accurate figure of the number of Nigerians that have health insurance.  Conflicting figures are used by different organisations when making presentations on healthcare financing in Nigeria. At Nigeria Health Watch’s 2017 Health Watch Forum, “Does Leadership Matter?”, the NHIS Executive Secretary stated that less than 1% of Nigerians had health insurance. Has that number changed in the last year? What is the current coverage? It appears to be quite a difficult task for the NHIS to provide timely periodic updates of Nigerians with health insurance. In contrast, the National Pensions Commission (PENCOM) provides a breakdown of Nigerians that participate in its contributory pensions scheme. The map above shows disaggregation of contributory pensions in States based on existing laws enabling pensions contributions.  To be sure, PENCOM and NHIS are both agencies of the federal government of Nigeria.

3. Why does the Nigerian government not enforce a simple regulation that every corporate organisation in Nigeria has to show evidence of its health insurance provision in Nigeria?

The Pensions Reform Act (2014) applies to public sector employees at federal, state and local government areas. It also applies to private sector organisations who employ 15 or more staff. In a way, pension is mandatory for all employers of labour in Nigeria except for private organisations that employ less than 15 staff. Why is health insurance not mandatory for corporate organisations in Nigeria? Of recent, the Senate embarked on a process of reviewing the NHIS Act with the aim of amending it. This seems to have stalled. It is gratifying that states in Nigeria have been mandated by the National Council on Health to sign State Health Insurance laws. At the last count, about 17 States have signed their own laws. However, none have begun implementation. These State Health Insurance laws are mandatory for residents of each state. Hopefully, with full implementation, the pool of Nigerians with health insurance will increase appreciably.

Dr. Leke Ewenla, president of the Health and Managed Care Association of Nigeria (HMCAN), the umbrella body of HMOs licensed operators of the NHIS, during the investigative public hearing. Photo credit: Nigeria Health Watch

4. How can we make Health Maintenance Organisations (HMOs) more accountable for their clients, regarding access to care, the package of care, and satisfaction with their services?

The National Health Insurance Scheme defines a HMO as, “a private or public incorporated company registered by the Scheme solely to manage the provision of health care services through Health Care Facilities accredited by the Scheme”.  HMOs have been accused of mismanagement of N351billion paid to them for effective healthcare delivery in Nigeria. In 2017, the NHIS Executive Secretary said that HMOs returned about 92% of funds owed to the NHIS and also accused HMOs of funds mismanagement. At the 2-day investigative public hearing on HMOs operations last year, the Federal House of Representatives questioned whether HMOs were a necessity and if funds cannot be paid directly to hospitals for the care of enrolees. At the same public hearing, the president of the Health & Managed Care Association of Nigeria (HMCAN), the umbrella body of HMOs licensed operators of NHIS, defended operations of the HMOs, pointing out that health insurance premiums should be paid annually, but the NHIS and HMOs agreed on quarterly payments. This has been changed to monthly payments.

As it stands, HMOs are legal instruments for delivery of healthcare as defined under section 19 of the 2013 NHIS Act. Therefore, they cannot be wished away except if the NHIS Act is amended, a course of action that should be explored. All efforts must be made to make them more accountable to enrolees and the NHIS in the delivery of patient-centred healthcare.

5. Finally, where is the 1%? How can a country pass a Health Act and almost 4 years later, there is almost zero implementation of the new Act?

In October 2014, after 10 years of sustained advocacy by Civil Society Organisations (CSOs) in Nigeria, former President Goodluck Jonathan signed the National Health Act. Almost 4 years after this historic Act was passed, Nigeria is yet to budget for the Basic Health Care Provision Fund (BHCPF) which will be partly financed by the Consolidated Revenue Fund (CRF). It appears 2018 is the year that this jinx may be broken. The National Assembly is ready to pass the BHCPF if it is budgeted by the Federal Ministry of Health. Key components of the BHCPF include grants by international donor partners and funds from any other source. The international donor community has so far been silent about their contributions to the BHCPF, possibly because they are yet to see firm commitments from government on the release of funds from the CRF. If implemented, all funds coming into Nigeria for healthcare must be put into the BHCPF. Is the donor community ready for this? What accountability mechanisms are being put in place to ensure the BHCPF is judiciously expended? These are questions that government and CSOs must answer. For now, there should be sustained advocacy to push for the budgeting of the BHCPF in 2018.

As another critical election in Nigeria draws near, it’s time to cut through the noise of politicking. Nigerians must focus on what matters – Universal Health Coverage for every Nigerian.

What other areas do you think politicians in the coming election cycle must focus on to achieve universal health coverage in Nigeria? Share with us on our online platforms or send us an email to info@nigeriahealthwatch.com, and let’s make our voices heard for UHC in Nigeria.

Discussion5 Comments

  1. You’re asking the right questions. Pls get the News Network to take up these questions publicly in serial panel discussion with reps of key stakeholders. Let’s avoid the blame game there’s enough to go round… and profer solutions….

  2. Obiora Egbuniwe

    Dear Editor,

    Thank you for putting together, a well thought out constraints impeding the implementation of a sustainable and effective scheme. Not only did you address the Triple Aim, you engaged all the stakeholders. Sometimes, we fail to acknowledge that patients are the key stakeholders in the healthcare system.

    Other self-imposed barriers are when predetermined outcomes are set (inferior deliverables) with the intent to self enrich, lack of accountability, inadequate/dysfunctional regulatory bodies, and the lack of awareness. The scheme cannot be effective without adequate technological infrastructure and human resources. Efficiency in this space requires collaboration between clinical, technical, and business entities, hence Health Information Technology that will improve population health driven by a value-based system. The Stack Law is another enchilada.

    Until the right resources (human) with a common goal are brought together to initiate and create a charter to propel this program with achievable goals and metrics, the nation will continue to run in circles. When you fail to plan, you plan to fail.

    Obiora Egbuniwe, CPHIMS

  3. This is quite on point as universal health coverage is the way to go if we are committed to ensuring good health and well-being of Nigerians. In addition to financing, the ward health system should be implemented in all the states to be able to reach people where they live with the basic health care package. This is important as most wards do not have a functional primary health care center. Primary health care is not health care for the poor but healthcare center that is accessible, affordable and equitably distributed in the community with their full participation.

  4. Private Sector involvement at primary care level will be key to the success of the NHIS.
    We have to ensure sustainability of the NHIS by making primary prevention in appropriate facilities the back bone of our health care system.
    Currently this has been hijacked by quacks forcing physicians to move up a notch in the health care hierarchy.Many patients will often enter the health care system through a quack,physician involvement starts often at the Hospital level.This needs to be reversed if our health Care system is to perform well for all and become sustainable.

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