Stakeholders clarify positions on NHIS

Health insurance was bound to be difficult in selling, especially when it is mandatory. Social health insurance is much more herculean before a private employer of labour, who is asked to buy for his workers.

It is not for lacking the best of intentions, employers of labour could tell, but for the question of who should pay and the timing of such proposal in an uneasy economy. So, they would not condemn social health insurance, and would not endorse it either.

Meeting at an interactive and enlightenment session on active participation in Formal Sector Social Health Insurance Programme (FSSHIP), recently held in Lagos, the stakeholders unanimously applauded the initiative that aims to pool funds for the health sector to take care of the sick, including the less privileged in the society. Who should pay the workers’ contributions — employees or their employers — however changed the tune.

Already distraught by the state of the economy and increasing difficulty for business survival, the organised private sector felt uneasy at the proposed model. Issues were also raised about the antecedents of health insurance scheme in the last 17 years and the fact that NHIS, regulator by statutory provision, will be assuming the role of a provider, which is already allotted to the Health Maintenance Organisations (HMOs). .

Social health insurance is not entirely new. It dated back to 1999 and formalized in 2005 into what is known as the NHIS. It had largely been restricted to workers in the formal public sector, with plans to scale up into rural communities and the formal sector.

Experts argued that the goal was to address the problems of adequate funding in health sector and out-of-pocket syndrome in the population, and in addition, give universal health coverage for the citizenry.

There is very little of such success stories for health insurance in Nigeria today. Dr. Jonathan Ekeh of the NHIS, noted that only 7.5million of the Nigerian population has been covered till date. An HMO (operators of the scheme) said the figure is actually 4.2million (1.2m from public sector).

Ekeh said it partly accounts for why health financing is still poor in the country and 68 to 70 per cent of cost are from out-of-pocket, in a population already endemic in poverty.

He added that the social health Insurance, driven by the NHIS, is an all-inclusive system and reliable, “which is why we have chosen it in going forward.”

According to him: “It is key to NHIS because it ensures adequate funding for heath services, such that you’d marvel at the impact they are already performing. It is not by the million spent on health but efficiency to which the money has been put to use. NHIS is not here because they want to collect your money but for the interest of the health system, especially the less privileged,” Ekeh said.

The social health insurance proposes a contribution of 5.25 per cent of consolidated salary; jointly shared by worker and employer. Or 15 per cent of basic salary; with employer paying 10 per cent, while the worker contributes five per cent of his take-home pay.

“It is big money but nothing compares to the benefits NHIS offers. The role of NHIS is to develop policies on the overall health insurance practice in Nigeria and not to collect the money.

“What we are asking of the Organised Private Sector (OPS), is to be part of the solidarity contributory funds. Part of the problem is that it is still mandatory here, while it is compulsory in other places, but we all can voluntarily contribute towards a better society for all,” Ekeh said.

What do enrollees stand to benefit? According to the plan, enrollees are covered for all consultations and consumables at the primary health care level; for surgical procedure, hypertension, diabetes, snake and dog bites, opportunistic infections, mental illness, sexually transmitted infections, malaria, nutritional disorders, maternity care for both high and low risk pregnancies, post-natal care, neonatal care for 12 weeks following delivery, family planning education, all emergencies and surgeries that are not in the exclusion list.

Dr Christopher Okoh of the NHIS noted that the tertiary treatments were included because “local capacities for them are available” and requisite surgeries are now carried in tertiary hospitals like University of Nigeria Teaching Hospital, Nsukka; LUTH, OAUTH, LASUTH, DESUTH among others.

Partially covered (that is, enrollees would pay 50 per cent of the cost), are dialysis (to maximum of six sessions) and treatment of renal failure.

Excluded from the package are occupational injuries that is already covered by the Workman Compensation Act; non-work related injuries (under the purview of the National Emergency Management Authority (NEMA); family planning commodities, domiciliary visit, drug/ substance abuse; complex surgeries like cardiac, plastic, renal transplant, congenital abnormalities, In Vitro Fertisation (IVF), dental implants, cancer treatment and postmortem examination.

Okoh noted that accrued benefits and premium were determined based on prevailing health issues in the country.

Okoh and his colleagues were apparently sure of their product on the bright afternoon, but they could as well tell from occasional groans and side-talks from audience, that employers of labour and heads of Human Resource (HR) department of companies were least impressed.

Thrown to the audience, there was debate on who should pay the 15 per cent premium of an employee’s basic salary. Representative of the Nigerian Textile Manufacturers, asked why the NHIS did not request employers to pay for their workforce, instead of “bothering the poor workers that could barely feed from their meagre pay.”

Ajibola Oyekunle from UNILEVER was quick to point out that even the employers of labour were already over burden by huge wage bills.

Oyekunle noted that the timing was wrong. “We are in economic down time. We are hearing that Value Added Tax (VAT) will be higher on private sector. If this happens, it will affect even the hospitals, many of who are already skeptical of the entire system. I really support the plan but also very curious about its long term goals and its sustenance.”

Director General of the Nigerian Employers Consultative Association (NECA), an umbrella body for organised private sector, Olusegun Osinowo, was the first to voice the dissent in the minds of the prospective buyers.

Osinowo first gave credit to the plan, citing its prospect to foster and strengthen family ties. He likes the NHIS package because it will give members of his extended family access to cheaper health care, whatever it is worth.

He was, however, quick to add that he didn’t see either the employers or employees accepting to contribute extra fund into the scheme.

His words: “It will be a hard-sell for employee to migrate into the system. I don’t see any employer going to the workers to say they will have to pay from their salary.

“And to ask those that are already grossly burdened (business owners) to pay more to cover their staff, will be a hard-sell. In a society already burdened by corruption and gross mismanagement, everyone is bound to be skeptical. It is even difficult for the public employer to contribute not talk of the private.

“For now, the OPS will not want to be pulled into any social pooling system. We can work out different plans on our own. My appeal to NHIS is to find alternative funding mechanism,” Osinowo said.

Again, he called into question the business of the NHIS, as regulator or provider. By its enabling act, the NHIS body is saddled with policy formulations and to regulate activities of the HMOs. But by the social health insurance scheme for the formal sector, the regulatory body will also be assuming the role of operator and almost in competition with the HMOs.

Executive Director, Human Resources, Seven-Up Bottling Company, Femi Mokikan, was in sync with Osinowo, adding that the proposal, though innocent as it seems, is a potential tinderbox for industrial crisis.

“Asking employees to pay this thing will set the ball rolling for industrial crisis,” Mokikan said.

“At the end, employers will be forced to pay the 15 per cent to enroll their workers. The implications will be higher cost of doing business. Then, their will be retrenchment from the front, behind and all around. The scheme is good and no one will be against it, but the issue of funding mechanism.

“We will have a big challenge selling this to our workers. Even with NSITF that ask for just one per cent, it was still a tussle. The main strategic duty of the HR today is to reduce labour cost and not to add to it.

“We only need the right leadership that will cut current wastages and gross corruption in the system, to get the needed fund. We have the commonwealth, we only need to harness it for our needs,” he said.

Chief Executive Officer of Total Health Trust Limited, who also represented the HMOs at the forum, Dr. Ladi Awosika, queried the attempt by NHIS to go into competition with providers in the country.

Awosika said it was unfortunate that the same issues that had came to the fore in discussing health insurance in 2007 were still being repeated, showing lack of coordination in thoughs and plan for actual universal health coverage.

Reflecting on the proposed scheme, he said, “The public sector just think they can wake up and get everyone going. Any attempt to make both the rich and poor equal (equalization), I hear it is been worked out here, will not work. Social Health Insurance in South Africa has suffered from the same fate in the past 14 years and we dare not make the same mistake.

“Fundamentally, what is social health insurance in a country where over 50 per cent are unemployed? But we here are fond of re-creating the wheel, when the wheel is already there. We do this because of competing interests. The enabling laws and what needed to be done are already with us. In my mind, it is not for NHIS to be pooling fund. That is the job of the HMOs and we all only need to get our hearts together,” Awosika said.

Representative of the Executive Secretary of the NHIS, Femi Akingbade, said the parley was organised for stakeholders to air their views and agree on necessary amendments in going forward.

Akingbade noted that the NHIS choose the OPS because they are very organized and quite easy to reach them. Because they can come together, they are able to discuss what they expect and at the end of the day, the kind of quality they are expecting to get could actually be demanded, he said.

“The reception here today is coming from a side that wanted to know more about what we are doing. To us, it is a good opportunity to enlighten people and get feedback also, knowing what the expectations of the OPS are.

“We actually have other things in the pipeline. But someone still has to pay for health care and government cannot do it alone. That is why we are planning to partner with some private people while government also provide some funding too,” Akingbade said.