Over 170 Million Nigerians Without Health Insurance

…COVID-19, delayed law slow universal coverage
…Scheme fully back on stream, says NHIS

Coronavirus disease (COVID-19) pandemic and non-passage of the amended National Health Insurance Scheme (NHIS) Act have further slowed uptake of health insurance packages and Universal Health Coverage (UHC) in Nigeria.

More than 170 million Nigerians are still paying out-of-pocket to access medical services, forcing households and individuals to incur catastrophic health expenditure. This can exacerbate the level of poverty, analysts told The Guardian.

Critics worry that the NHIS has remained abysmal and coverage rate dropped, from over 10 per cent (5.6 million Nigerians) 10 years ago, to just barely 1.72 per cent (one million Nigerians) in updated statistics.

A study published in The Lancet, a medical journal, noted that more than ‘‘90 per cent of the Nigerian population were uninsured, despite the NHIS that was established in 2006. Less than five per cent of Nigerians in the formal sector are covered by the NHIS. Only three per cent of people in the informal sector are covered by voluntary private health insurance. Uninsured patients are at the mercy of a non-performing health system.”

Yet, another study showed that only three to five per cent of Nigerians (about 1.7 million and 2.8 million people) are on any form of health insurance.

The Guardian reliably gathered that Kwara, Cross River, Lagos, Delta, Ogun, Bauchi and Enugu have established health insurance schemes while other states are at various stages of setting up own programmes.

The National Health Insurance Commission Bill 2019 seeks to address NHIS challenges and also make health insurance mandatory.

The NHIS in Nigeria was launched in 2005 as part of efforts by the Federal Government to achieve UHC with financial risk protection mechanisms.

However, 15 years after the launch of the programme, stakeholders say only about four million Nigerians have any form of health insurance. But the NHIS say over 10 million Nigerians are currently covered under various programmes by the scheme, state agencies and private plans by Health Maintenance Organisations (HMOs).

Unfortunately, mainly Federal Government employees are covered by health insurance and this is mainly through the formal sector social health insurance programme (FSSHIP) of the NHIS.

FORMER President, Pharmaceutical Society of Nigeria (PSN), Olumide Akintayo, told The Guardian: “It remains the same comatose project it has been in the last seven years. What do you expect when the coverage rate drops from over 10 per cent 10 years ago to barely 1.72 per cent which we are left to contend with today. As far back as the era of Femi Thomas, which I think was 2014/15, the enrolment or coverage rate had dropped to 1.72 per cent as far as the NHIS is concerned.

“It is noteworthy to state that there are some private health insurance plans in the organised private sector. These ones are doing well.

“Even the needless and unending amendments of the existing statutes, which has been our portion, has not achieved anything because the ulterior motives of the sponsors of the amendment bills oftentimes override the public interest.”

Akintayo said no state government had a functional health insurance programme. “I cannot give you a figure, but they are less than 10. Lagos State and about five or six others have attempted to commence programmes, but I am not aware they run impactful programmes,” he said.

Akintayo said enrollees on the NHIS had also been affected by lockdowns and all other restrictions imposed by government. He said operations in the pharmaceutical sector could not be optimal from manufacturing to dispensing of drugs because of ban on importation, which affected pharmacists negatively because practitioners were too import-dependent.

MEDICAL Director of Optimal Specialist Hospital, Surulere Lagos, Dr. Ugochukwu Celestine Chukwuneye, told The Guardian that many states were making attempts to have functional health insurance.

“The exact number of Nigerians on health insurance cover is not available but it is generally believed to be below three per cent of the population.”

The Consultant Obstetrician and Gynaecologist said because of fear of contracting COVID-19 disease in hospitals, the number of enrollees visiting hospitals dropped drastically over March and April 2020, but started rising again in May 2020, reaching pre-COVID 19 levels by August 2020. “The picture may be similar worldwide. The significant drop in the number of enrollees visiting hospitals in those months, would translate to significant financial savings by the HMOs,” he said.

Chukwunenye explained: “The present costs in managing COVID-19 disease patient make it clearly outside what health insurance can cover in our country but countries with well developed insurance schemes may offer limited coverage. It is likely that in the near future, costs will drop drastically, bringing it within the reach of health insurance.”

Head, Media and Public Relations of NHIS, Mr. Ayo Osinlu, said that, contrary to knocks from critics, the Scheme was back fully to business, waxing strong and breaking new grounds in its renewed focus and pursuit of core mandate.

He explained: “NHIS has functional offices in all states and the Federal Capital Territory (FCT) Abuja. As of today, 34 states, including the FCT, have in place functional state health insurance agencies at various levels of implementation.

“There are over 10 million Nigerians currently covered by health insurance under various programmes by NHIS, State health insurance agencies and private plans by HMOs.”

He said NHIS had been proactive in fight against COVID19. Osinlu said the scheme, as part of its rebranding agenda, reverted to quarterly upfront payment of capitation to healthcare providers.

Capitation is a payment arrangement for health care service providers. It pays a set amount for each enrolled person assigned to a health facility, per period of time, whether or not that person seeks care.

Osinlu said this is a policy decision carefully taken by management to enable enrollees assess care without any hitch all through this period and beyond. “COVID-19 is a public health emergency. It is, therefore, not possible for it to be covered by any health insurance programme because while health insurance is pre-paid and the benefit package actuarially pre-determined, a medical emergency or pandemic is sudden and unexpected. It, therefore, cannot be budgeted and provided for in advance,” he said.

But Executive Secretary, Delta State Contributory Health Commission (DSCHC), Dr. Ben Nkechika, told The Guardian: “There is no definite figure of coverage but is estimated at five per cent of the Nigerian population.”

Nkechika said all states in Nigeria had health insurance schemes but at different functionality status.

He, however, said COVID-19 has not had much effect in Nigeria. Nkechika said the pandemic could be covered under NHIS or any health insurance only under a mandatory system where there is a critical mass involvement in the health insurance programme across the country.

“Volume will drive down service cost,” the medical doctor said.

EXECUTIVE Secretary, Enugu State Agency for the Control of AIDS (ENSACA), Dr. Chinedu Arthur Idoko, told The Guardian: “The early starter states with NHIS were Cross River, Bauchi and Enugu States. However, many states, if not all the states in the federation, are in different stages of buying into the programme. With this comes strengthening of the various facets of it for full institutionalisation and functionality.”

The public health physician added: “Many states have set up the health insurance schemes/universal health coverage agencies. The awareness of the health insurance system has indeed risen in Nigeria.”

Idoko said COVID-19 had of course changed the dynamics of things locally and internationally, including the health insurance system. He said a lot of attention; funds, health manpower and policies had been directed towards combating COVID-19. “As the COVID-19 is controlled, a lot of things will be back to running normally and on a progressive pedestal. Health insurance is one of it,” he said.

To address the issue of amending the law establishing NHIS and other challenges faced by the agency towards meeting its mandate of putting at least 70 per cent of Nigerians on health insurance, stakeholders recommend integration of all health insurance systems in Nigeria, better funding for the Basic Health Care Provision Fund (BHCPF) and improved quality healthcare services delivery at accredited Health Care Facilities (HCFs).

The BHCPF is a key component of the National Health Act (NHAct), which was signed into law in 2014. BHCPF aims to extend Primary Health Care (PHC) services to all Nigerians by substantially increasing financial resources.

Half of the Fund will be used to provide a basic package of services in PHC facilities through the NHIS; 45 per cent will be disbursed by the National Primary Health Care Development Agency (NPHCDA) for essential drugs, maintaining PHC facilities, equipment and transportation, and strengthening human resource capacity; and the final five per cent will be used by the Federal Ministry of Health (FMoH) to respond to health emergencies and epidemics.

Reacting to delay in passage of the amended NHIS Act into law, Osinlu said: “The process of amending NHIS law has gained tremendous traction, especially in the Senate. Thanks to the Chairman, Senate Committee on Health, Dr. Ibrahim Oloriegbe who sponsored the bill for the amendment.

“Significant progress has been made in the legislative process, including first and second reading, public hearing, retreat to review the hearing report, third reading and passage in the Senate. Concurrence passage by the House of Representatives is the expected next step before bill is ripe for presentation for Presidential assent.”

However, Osinlu said besides amending the law, there is also a need to provide an effective coordination of health insurance in the country to remove fragmentations and unify the system with common standards and data.