National Health Insurance Scheme: Achievements and challenges
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The Nigerian Health Sector is no doubt one of the cardinal sectors whose successful reform will definitely shape the direction and pace of national economic growth and development. However, the sector has witnessed several years of neglect, decay of infrastructure, poor funding and inappropriate human resources management coupled with colossal depletion of trained personnel (brain drain).
At the inception of President Olusegun Obasanjo administration in 1999, Nigeria was reported as having one of the lowest annual budgets dedicated to the health sector in Africa (less than 5 percent of total budgetary allocation). Resource allocation for the sector between the Federal, State and Local Governments was inefficient and unbalanced. The quality of health services and facilities and drugs were either very low or there was prevalence of fake, substandard and unregistered health institutions. The resultant effects of these were that at some point, our health institutions became shadow of themselves and consequently reduced to poorly managed “consulting clinics” which could hardly handle serious health complications and surgeries. This ugly development took its toll on the lives of the ordinary Nigerians who could not afford to travel abroad for quality healthcare attention, and this caused an increase in mortality rates and incidences of ill-health and general poor health indices.
However, developing and implementing a sustainable healthcare financing strategic framework is a key success factor for health sector reforms in Nigeria and in improving the health status of a majority of the people, both in the immediate, intermediate and long-term perspective. Such a strategy would aim at striking a strategic, sustainable and fair balance through a cocktail of government budget; social health insurance; private health insurance/managed care funding arrangements; and to include non-governmental and development partners’ support; as well as mutual and community social health insurance funds, with limited out-of-pocket sources to finance healthcare services.
Speaking recently on the National Health Insurance Scheme – achievements and challenges, the Executive Secretary of the NHIS,. Mohammed Dogo-Muhammad, said that this could only be achieved through the NHIS, established by the Government on June 6, 2005. The NHIS represents a very promising sustainable healthcare financing strategy. The agency has a mandate to work progressively towards achieving universal health insurance coverage for all Nigerians. Indeed, the Public Sector Social Health Insurance Programme (PSSHIP) was launched formally in June 2005 and has so far covered 2,162 million enrolees consisting of Federal civil servants and their dependants in the Ministries, Agencies and Extra- Ministerial Departments (MDAs), Armed Forces, the Police and other uniformed personnel. In a bid to extend coverage to the states, the scheme embarked on high level advocacy to the State Chief Executives and other policymakers, to solicit for their support and subsequent folding-in into the programme. The visits to the states have resulted in several activities which have taken place in many states in form of advocacy and sensitization. Two states, Cross River and Bauchi have joined the scheme. The number of enrolees that have folded into the programme in Cross River is 34,165, while in Bauchi State we have 67,007.
Furthermore the Scheme has signed a Memorandum of Understanding (MoU) with Enugu State Government. The State Government has been requested to make the initial financial contribution, after which the accreditation of healthcare facilities and registration of the State workforce will commence. Sixteen other States are at various stages of folding-in into NHIS Public Sector Programme.
The scheme has conducted a nationwide inventory of existing Civil Society Organizations, Community Based Organizations, Cooperative Societies, Existing Community Based Health Insurance Scheme’s and Occupational Based Groups. On the basis of defined criteria, NHIS is expected to select about 50 groups (from the inventory) to serve as viable entry points for piloting CBHI in the country. The selection will be one group in each state and FCT. Up-scaling shall be achieved through continuous identification and engagement of viable groups in partnership with all stakeholders. The programme was eventually flagged off at Isanlu in Yagba East Local Government Area of Kogi State on 17th December, 2011, thereby marking the commencement of the implementation of the programme.
To ensure the protection of the vulnerable groups and promotion of access to good health care, NHIS engaged in series of meetings and discussion with international partners for health on NHIS/MDG-MCH project, such as the meeting with Prof. Jeffrey Sachs, the Special Adviser to the United Nations Secretary General on Millennium Development Goals. NHIS with funding from the OSSAP-MDGs has achieved 100 percent health insurance coverage in 12 states of Niger, Gombe, Oyo, Bayelsa, Imo, Sokoto, Bauchi, Yobe, Jigiwa, Katsina, Ondo and Cross River with 1,600,000 pregnant women and children under 5 covered in 86 local government areas (LGA).
NHIS is also bringing in the organized private sector (OPS) into the scheme since the launch of the Formal Sector Programme in 2005. Since 2009, efforts were intensified to achieve this goal, including a structured engagement of NECA towards covering the employees of the OPS with social health insurance. Many private companies are, however, already participating in the programme.
In an effort to develop a programme for voluntary participants, the scheme launched the programme on 17th December, 2011 along with CBHI at Isanlu in Yagba East Local Government Area of Kogi State. Some HMOs are already registering enrolees under this programme.
A blueprint has been developed and sensitization workshops for all stakeholders have also been organized in the six geopolitical zones. Meetings are being held with the Pension Commission and other stakeholders to finalise the development of the programme.
As part of the programme to cater for retirees, NHIS has developed a position paper with a view to selecting a possible option for the development of a blueprint for the coverage of retirees. A national stakeholders meeting was held in the last quarter of 2010 in order to determine the financing option and other operational modalities. This is to enable the scheme to come up with a final blueprint for the operation of this programme. For the military retirees, arrangements are being finalized to get the approval of the Federal Executive Council to evolve a health insurance cover for them. The scheme has finalized arrangements for providing a health insurance cover for the ex-militants. This has been done in collaboration with the OSSAP-MDGs. The registration of the ex-militants under the scheme has already commenced.
NHIS in collaboration with the National Agency for the Prevention of Traffic in Persons (NAPTIP) commissioned a consultant to carry out a feasibility study on how to provide a health insurance cover for the victims of human trafficking. The study has been completed and in the process of developing a framework on how they could be registered under the scheme. The scheme in collaboration with NPHCDA has also worked out modalities for providing an health insurance cover for the midwives that have been employed by NPHCDA. They have already started accessing care under the NHIS. With an Act which has been amended with all stakeholders involved and has gone through second reading at the Federal House of Representatives, the scheme has been able to accredit a total of 4,146 healthcare facilities, 61 HMOs, 24 banks, 19 insurance companies and 10 insurance brokers.
However, the scheme is confronted with a number of challenging factors. First of all, Nigeria is faced with a huge population, over 70 percent in the informal sector, thus evolving a health insurance programme to cover this population has posed a big challenge. Again, the absence of a robust and functional Health Information System (e-NHIS enterprise system) and the lack of adequate modern Information Technology (IT) infrastructure as well as the acceptance of capitation at primary level and payment for secondary and tertiary care through fee-for-service has continued to be a challenge. The provision of multiple provider status to a facility as primary, secondary and tertiary provider has brought distortions within the referral system and tends to limit the achievement of one of the objectives of the scheme.
Health Insurance is a nascent industry in the country and therefore there is a dearth of skilled manpower in healthcare financing and insurance. The scheme is expected to achieve universal coverage by the year 2015. However, a very big segment of the Nigerian population has been described as vulnerable and lacking the financial ability to pay for healthcare services. This group, therefore solely rely on government intervention. To this end, a vulnerable group fund needs to be established to administer this peculiar service. Innovative ideas like the “1k/sec initiative” from the utilization of mobile phone will capture a substantial amount of money, especially now that SIM Card lines have gone up to 110 million lines.
Indeed a strong correlation exists between health, economic development and poverty alleviation. Therefore, adequate financing of healthcare services play a significant role in shaping the direction and pace of national economic growth and development. Securing stable and sustainable ways and means by which funds are mobilized to pay for essential health services is, however, the most important policy goal and objectives of a national health system. The National Health Insurance Scheme is therefore one of the singular intervention towards implementing a sustainable financing mechanism in Nigeria.