An effective mandatory health insurance programme has long been identified as necessary to protect Nigerians from out-of-pocket payment for healthcare, a situation partly blamed for the country’s grim health indices.
Millions of Nigerians continue to face health mishaps due to causes mostly preventable or at least treatable.
This is partly because they cannot afford quality care since health insurance has largely been ineffective.
President Muhammadu Buhari acknowledged this when he chose this year’s study topic for the NIPSS – Nigeria’s foremost think-thank institution – to find a solution for funding healthcare in the country.
Nasirudeen Usman, the NIPPS director of studies in an interview with PREMIUM TIMES had explained that the president was very concerned with the burden of out-of-pocket spending on health.
“That is why he chose this topic,” Mr Usman, a professor, said.
Meanwhile, President Buhari is yet to consider signing two critical health bills adjudged by experts to represent a one-way ticket for reducing out-of-pocket spending through mandatory health insurance.
The National Health Insurance Commission (NHIS) Bill provides a policy framework that makes health insurance mandatory in Nigeria. The second is the bill to establish the FCT Health Insurance Agency. They were among the 26 bills passed by the 8th assembly before their tenure ended on July 11.
While President Buhari rejected the FCT health bill, among 17 other bills, no communication has been made on the NHIS bill so far.
“Though the FCT health insurance bill was rejected, we are still hoping he will consider signing the NHIS bill which is still on his table,” said Lanre Tejuoso, the then chairman senate committee on health, who played a major role in the successful passage of the NHIS bill.
Players in the health sector fear that about145 women of childbearing age and 2,300 children under 5 years of age will continue to die daily in Nigeria if the country’s health insurance system remains in its current state.
About 70 per cent of Nigerians pay out-of-pocket for health even though the country launched its health insurance scheme (NHIS) since 2005 – the same year neighbouring Ghana launched its own.
Today, only five per cent of Nigerians have health insurance, while Ghana’s scheme has covered over 50 per cent of its population.
Asides administrative encumbrances, it is believed that a major limitation to making the NHIS a success it that it made health insurance optional.
“The major problem with the (old) act is that it failed to make health insurance compulsory,” said Mohammed Usman, former House of Representatives Committee Chairman on Health. “Insurance policies are meant to target the generality of the population.”
With a new act, practitioners in the health sector believe some other functions of the scheme will be clearly stated.
Amended NHIS Act
In April, the 8th assembly passed the NHIS bill into law after a long rigorous legislative process.
“We were able to achieve this through serious one on one engagement with all the lawmakers,” said Mr Tejuoso, a former senator representing Ogun Central.
Titled “National Health Insurance Act (Repeal and Re-enactment) Bill 2019”, the new bill, when made law is expected to invalidate some aspects of the old law (2004).
Some of the loopholes in the old act to be revoked with the new bill include:
I) Making Health Insurance Mandatory.
II) Subsidising Premium Payments for those who cannot afford it.
III) Stating roles of states which were not clearly stated in the current NHIS Act.
IV) The enforcement of the NHIS Act through the implementation of the Basic Healthcare Provision Fund (BHCPF).
V) Limited Regulatory Powers of the NHIS to effectively carry out its functions.
Since the bill was passed, campaigns and advocacy calls have been channelled to the president, urging him to give a nod to the bill. He is, however, yet to heed.
“If by May 29, the president did not give assent to the bill, we might have to start the process all over again,” Ben Anyene, chairman of the Health Sector Reform Coalition (HRSC) said.
He spoke at an event in April by health advocates to raise awareness and fast-track presidential assent to the bill.
The fear was that the bill will suffer a major setback if President Buhari did not assent before the transition of a new government.
The president, however, kept mum on the NHIS bill even though he has continued to sign bills passed by the 8th assembly. Between July and August, he signed at least 12 such bills.
Attempts seeking clarification from the former presidential liaison on National Assembly matters, Ita Inang, were unyielding. He requested to be given time to get clarifications when contacted but never responded.
Bureaucratic processes and poor counsel are majorly what is holding the president back from assenting to the NHIS bill, according to Mr Usman.
“As per the law, he is the same president ruling his second term. I don’t know precisely when these letters were transmitted to him but I know since it’s the same government, it should be the same process,” he told this medium in a phone interview on Friday.
The former lawmaker said there is no law which says he (Buhari) should not assent “because the work has been done”.
“There is no reason for him not to assent and that is my position on that. The problem is the bureaucracy in government. This is some of the things that do not allow us to make progress because we allow bureaucracy to hold us back.
“We know how much time and resources that have been put into this. We worked with both local and international health organizations advocating for this bill.
“Not signing it has a lot of implication because it means going back again. It’s better we do this now and forge forward.”
A country that makes health insurance optional for its citizens will find it very difficult to achieve Universal Health Coverage (UHC), according to experts.
For Obikezie Obioma, a health consultant, this is a major reason why the Nigerian government should promptly sign the NHIS bill to make health insurance mandatory.
“In a society where health insurance is optional, there is a high tendency for adverse selection – a situation where only those only those with the greatest likelihood of illness goes ahead to purchase health insurance,” Mr Obioma told this newspaper.
“Where it exists, mandatory health insurance maximises the chance of cross-subsidizing or distributing or health care risks between the healthy and the sick, the rich and the poor as well as the young and the not very young.”
For Mr Tejuoso, the NHIS bill which ensures mandatory insurance is the only game-changer for a positive health outcome in Nigeria.
“Millions are dying due to lack of access to affordable and qualitative health care. We will continue to languish in this state, killing ourselves financially if we fail to sign this bill earlier now,” Mr Usman noted.
Another ‘rejected’ bill
The failure of the NHIS to deliver heralded the quest for the establishment of State Health Insurance Schemes (SHIS).
“SHIS offers each state a more feasible platform to manage their own homogenous cultures and context in taking health insurance to the last citizen,” Mr Obioma said.
Many states such as Lagos and Niger have begun implementation. Having SHIS is a major criterion for states to enjoy the Basic Health Care Provision (BHCPF).
The BHCPF is one per cent of the federal government Consolidated Revenue and contributions from donor grants set aside to fund the basic health needs of Nigerians. It was approved by the National Assembly in 2018.
To access the fund, states must establish their SHIS among other criteria. So far, the FCT and other states are yet to comply largely because they do not have a state health insurance agency.
This was why advocacies intensified for the establishment of the FCT SHIS to provide care for Abuja residents who are not under the NHIS.
“The structural set up that follows the establishment of SHIS provides a near-ideal structure needed for the BHCPF in a more transparent and accountable manner,” Mr Obioma said.