Lagos, Nigeria’s most populous city, is among the few states in the country on the verge of kick-starting its state-run health insurance scheme to drive Universal Health Coverage (UHC).

The Lagos State government said it is, however, in no rush to fully roll out the scheme which it said was made mandatory for all residents.

This they said was to avoid drawbacks that contributed to the failure of similar initiatives in the country.

Government officials and health experts provided updates on the scheme and explained various steps being taken to ensure it will be sustained once it is fully implemented.

They spoke during a series of engagements with some Senior Executive Course participants of the National Institute for Policy and Strategic Studies, (NIPSS) between Monday and Tuesday.

The NIPPS delegation is in the state for a study tour of its health sector. The visit is coordinated by NIPSS in collaboration with the Development Research and Project Centre (DRPC) through PACFAH@Scale.

Long road

On Monday, Adetokumbo Fabamwo, the Chief Medical Director, Lagos State University Teaching Hospital, gave a lecture on “Stakeholders Perception on Universal Healthcare Delivery and Funding in Lagos State”.

He broke down the successes and failures of various initiatives the state adopted to fund healthcare since the inception of the fourth republic in 1999.

“We started with the free health scheme launched in the administration of Bola Ahmed Tinubu in 1999,” he said.

He said the free-health scheme was supposed to provide care for three categories of citizens: Children under 12; elderly over 60 years; state public servants; pregnant women and the destitute.

Mr Fawambo, a professor, however, said the scheme failed because actual beneficiaries could not be authenticated. He also said lack of sustainable funding and poor universal applicability made the scheme to collapse.

The medical doctor further explained how the state in 2007 launched the Community Based Health Insurance Scheme (CBHIS) to substitute the free healthcare scheme.

Mr Fawambo said the CBHIS was unable to cover the state as it was targeted predominantly at the informal sector workers and offered a package of prepaid healthcare services for enrolled members of the community.

Mandatory State Health Insurance

With the unsuccessful stint of previous schemes, the Lagos State House of Assembly in 2015 passed the state health insurance scheme bill. Last year, Governor Akinwunmi Ambode signed it into law.

Bayo Aderiye, the chairman, Health Service Commission, in his presentation, said the government resolved to make the scheme compulsory for all residents to avoid the mistake made in the uptake of the National Health Insurance Scheme (NHIS), which was made optional.

NIPSS delegation at an interactive session with official of Lagos state government at the office of the Secretary to the state Governor.

The NHIS was created 14 years ago to reduce out-of-pocket spending on health services but the scheme has been stifled by a leadership crisis, corruption, legal, political and technical encumbrances.

Today, only about five per cent of Nigerians are covered. It is believed that the major limitation to any progress is the state of the Act establishing the scheme, which made insurance optional.

Mr Aderiye said all residents must have Lagos State Residents Registration Agency (LASRRA) cards to benefit from this scheme.

He said the uptake of the scheme will mark the end of free healthcare for every segment of the population in the state, “since the law envisages that no resident will be left behind by the time full implementation starts.”

Model

Earlier, Mr Fawambo, CMD Lagos University Teaching hospital, detailed how the scheme will be run.

According to him, enrolment is categorised into family and single units.

“In family enrolment, the beneficiary is expected to pay a premium of N40,000 yearly per family of six while a single enrollee will pay N8,500.”

The professor said government subsidised the premium for public servants in the formal sector.

“For family premium, civil servants will pay 25 per cent or N10, 000 while government pays 75 per cent or N30, 000.”

Meanwhile, Obioma Obikeze, a consultant for DRPC, expressed concern over the payment arrangement for civil servants. He said if the 25 per cent premium for civil servant cuts across all level of workers, “those at the lower level will be disadvantaged”.

lagos state permanent secretary, Adesina Odeyemi recieving the NIPSS delegation on Monday.

“If people at grade level 1 pay same premium with permanent secretaries, the aim of equity of distribution which is the fundamental prerogative of UHC is defeated,” he said.

Mr Fawambo, however, maintained that the 25 per cent (N10,000) premium cut across all grade levels in the service. “I don’t think N10,000 will be too much for any worker in Lagos to pay every year for health.”

Backstory

Health insurance has been globally recognised as the fastest route for any country to achieve Universal Health Coverage.

With health insurance, it is believed that out-of-pocket expenditure for health, which has placed many families in severe financial dearth will be relegated.

Experts say 70 per cent of Nigerians pay out-of-pocket for health even though the country launched its health insurance scheme, NHIS, since 2005.

The NHIS has been a cesspool of fraud, corruption, and controversies. While millions of Nigerians remain uncovered, the few enrolled under the scheme are complaining of inadequate service delivery.

With the failure of the NHIS to deliver, the quest for state health insurance intensified.

Just like Lagos, many other states have begun implementation of their SHIS.

Adetokumbo Fabamwo, the Chief Medical Director, Lagos State University Teaching Hospital recieving honorary award from NIPSS after an interactive session.

They include Delta, Bauchi, Kaduna, Sokoto, Abia and Anambra. Others are Bayelsa, Niger, Kwara, Kano and Imo.

But as it is with NHIS – currently dogged with multiple challenges – experts believe health insurance in states will not also work if proper implementation plan is not put in place.

PREMIUM TIMES reported last December that the Nigerian Medical Association (NMA) directed all doctors not to participate in any State Health Insurance until there is “meaningful engagement” between the government and stakeholders.

Legislative intervention

This, among others, has led to calls for a repeal of the NHIS Act and the enactment of a new one. With a new act, practitioners in the health sector believe how the SHIS should function will be clearly stated.

NIPSS delegation in a meeting with the SSG.

Titled “National Health Insurance Act (Repeal and Re-enactment) Bill 2019”, a new bill to invalidate some aspects of the old law (2004) has been initiated.

The bill passed third reading at the Senate about a month ago. It now needs presidential assent to fully become law.

Policy makers and health experts are of the view that it will take another rigorous legislative process if President Muhammadu Buhari does not assent, on or before midnight of May 29.

SHIS: Optimism in Lagos

Despite these concerns, stakeholders in Lagos are optimistic that by the time the state begins full implementation of its health insurance scheme next month, it will effectively change the landscape of health insurance in the country and become the benchmark for Universal Health Coverage.

According to Jide Idris, the state commissioner for health, about 34 per cent or 120, 000 residents have been enrolled.

He said the government is currently creating awareness and capturing people into the scheme.

“All other funding schemes will collapse into the state health insurance once its launched,” he noted.

Meanwhile, the NIPSS delegation presented honorary awards to various state actors they engaged so far in their tour of Lagos, one of the fastest growing cities in the world.