Many challenges of implementing health insurance scheme in states

NHIS undergoing reforms to fast track attainment of universal health coverage

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

In fact, The Guardian investigation revealed that more than 170 million Nigerians are still paying out-of-pocket to access medical services and out-of-pocket payments can make households and individuals incur catastrophic health expenditure and this can exacerbate the level of poverty.

Critics say the NHIS has remained nonfunctional and the coverage rate has dropped from over 10 per cent (5.6 million Nigerians) ten years ago to just barely 1.72 per cent (one million Nigerians) today.

Unfortunately, the states just like the Federal Government are not faring any better. Indications from health insurance schemes in the States suggest most of them are tagged ‘free’ and therefore unsustainable. While states like Delta have a functional health insurance programme, the scheme is still either nonfunctional or still in the pipeline in most others.

Cross River
Cross River State has a free “Health Insurance Scheme” otherwise known as “Ayade Care” which was launched in 2016 in the state to provide good and affordable healthcare services to the people.

The state Governor, Senator Ben Ayade had signed into law the free health insurance scheme specifically targeting the less privileged in the state as the “Ayade Cares” scheme “is a brother lending a hand to another brother with all of us standing for all of us, a policy for the people”. The Core Implementation Team (CIT) has been put in place to ensure a formal take-off and implementation of the programme.

But so far the scheme has not taken off fully as there are grey areas the Nigeria Labour Congress (NLC) and the Trade Union Congress (TUC) are insisting must be cleared by the government before they will participate in the programme. Hence a series of meetings have been going on to ensure its take off. Labour is suspicious of the scheme as it sees it as a way of exploiting innocent civil servants hence they said “our understanding of taking off maybe they should begin to deduct the N1, 000 contribution from each civil servant in the state”.

The former Chairman of TUC, Mr. Clarkson Otu said, “we are insisting that if the government wants to start as recommended by the House of Assembly, they should make funds available for the scheme so that we can see the commitment of the government in that regard before we can see that they are serious. Anything short of that they should not touch our money. Our position is clear and that is they should not deduct. Government talks of a take-off grant, which they have not released so they can not convince us that they are serious. If you say your seriousness will start from taking the deduction from civil servants, we say no, we will not accept that. If you release the take-off grant to that agency, release your one percent from your consolidated revenue fund every month then we can convince workers that the government is serious. Anything short of that we are saying they should not take anybody’s kobo”.

However, the State Commissioner for Health, Dr. Betta Edu said, “As you are aware we have the law and we have done all the operational guidelines and have also finished the benefits package. The next point for us is the enrolment proper and it will be flagged off by the third week of this month”.

On the initial take off fund, she stated, “we have little over N200 million and we have and an IT investor coming in with the software and hard drive which amount to almost $500, 000”.

On the challenge with Labour as regards deductions for the scheme, she said, “labour is on our side and they are happy about it but however they need us to start the enrolment before the deduction can start. We had a meeting a week ago in my office. We are expecting all Cross Riverians to participate in the programme but we are actually targeting about three million people and we have given ourselves a different timeline to a different number of persons ”.

Edu who was the then Director-General of the Cross River State Primary Health Care Development Agency when the scheme was flagged off, said, “the target from all the sources is that every month at least we should have N1billion put into health care from the government, the premium from people, international donor agencies and even gifts from individuals and philanthropic organisations. The day the law was signed we were able to raise N50 million”.

She explained that the N1, 000 which everybody is paying will not be able to provide that level of health care the government is thinking about as “government will equally be investing money into the health care insurance to make it work. Donor agencies, the World Bank will equally be expected to put in some financing to make it work. It’s going to be a collaboration between whole lots of stakeholders and as such transparency, accountability remains the watchword. The World Bank will not want to put their money into insurance that is a fraud and they have criteria that this insurance must go through and fit in”.

Edu said, “for the running of the insurance, picking up the money, looking through it will be done by the Health Maintenance Organisation (HMO), in collaboration with the World Bank, United Nation and several other agencies that will help in control and check. The government is bringing itself out of handling the fund so that it can be as transparent as possible and everyone can be involved in this process. We want our people to be able to hold us accountable for delivering quality health care services to them.

Giving details of the insurance scheme, Edu said, “given the present economic downturn people can longer afford to pay for their health bill. You have people who come down with lots of diseases and cannot afford to buy drugs, you have women that are pregnant and cannot go to access quality health services because they cannot afford it, the governor sat back and thought about how we can help our people and what is that policy that we can put in place that will enable every Cross Riverian have access to quality health care and that was how he came about the health care insurance scheme.

“It is targeted at the poorest of the poor to ensure that they can have access to quality health care service. The bill is exempting children under five, pregnant women, aged people or elderly persons above the age of 65, and people who are mentally and physically challenged. We are taking into consideration that they will not be able to work and generate income to pay for this insurance scheme. The governor has recognized that there are people in the society that are very poor and may not even be able to afford N1, 000 he is going to make an exemption for that little percentage of people living in the state that cannot afford it”.

The scheme according to her, “will protect us against catastrophic health expenditure that would further impoverish our people. You know health is a priority. Even if a man does not have money or he has N5,000 left and he is dying, that man will prefer to spend that N5,000 to stay alive than ever to feed the children. So we are saying even at a point that you are sick and you need this money and probably you cannot afford it because the health bill at that point is about N400,000 with the rising cost of everything in Nigeria, rather than giving up we are saying put just a token of N1,000 into a central puss every month and at a point that you are ill, whether you have money or not you can just walk into a health centre and access a quality health care”.

She said all civil servants need to buy into the state health insurance scheme as “for instance, you are working in state parastatal and you have four kids and in a month you have to treat one for malaria, diarrhea and put the bill together, it weighs beyond N1, 000 or you are suffering from diabetics which you have to take one tablet of a drug every day to keep your blood sugar in check, the total amount of money you will spend in a month is well beyond N1000.

“The governor a meticulous person, first we started with sensitization going through the 196 wards in the state sensitizing our people on the need to buy into the insurance scheme. Town hall meetings were held and we spoke with religious and opinion leaders and others”.

Edu stated that the health sector in Cross River State has not had a smooth ride, a common phenomenon with every other sector. However, “the health pyramid starting at its base, the Primary Health System to the Tertiary and advanced tertiary is currently receiving a boost. We now have a fully functional State Primary Health Care Development Agency with a view to positioning the state to benefit fully from the provisions in the National Primary Health Care act and revert the health pyramid to sit on its base (meaning the primary health care centres will handle most of the illnesses in the community with special cases going to the secondary and tertiary health institutions.

“The secondary and tertiary institutions are not left out as the “Ayade Care” (State Health Insurance Scheme) law which is a replica of the National Health Insurance Scheme with modifications that makes the financial burden so minimal that some elites and stakeholders think the premium is too small as such must be a joke. The state plans to really turn the state into a medical tourism haven of which discussions are ongoing with investors and partners across the globe”.

She stated that the State currently has 1,013 Primary Health Care facilities built by government, communities, and concerned individuals over the years, and with the coming of the agency, the state is better positioned to access the National Primary Health Fund, including the USD1.5 million and several other intervention funds which will go a long way in giving these facilities a facelift, provide drugs, hire skilled health workers and provide quality health services 24 hours”.

Rivers
In Rivers State, there is no functional health insurance programme yet, the process is still in pipeline. The people still pay to access health care services.

Findings revealed that even, the medical workers in State Government Hospitals pay to access drugs like paracetamol in the hospital pharmacies.

It was gathered that some people have enrolled in the NHIS in the State but the scheme is yet to take off properly.

The Guardian gathered that the state adopted a programme called the Rivers State Health Contributory Protection Scheme. The plan for the scheme is to have mandatory health insurance cover to all citizens and to capture both the formal and the informal sector.

However, in 2018, a Bill was sent to the State Assembly to highlight the guidelines on how the programme was to be drawn.

The bill was expected to create an agency known as the ‘Rivers State Health protection Bill’ to manage the process of the Statewide contributory health insurance scheme.

Sequel to that, stakeholders’ engagement was carried out and consultations were made.

And to achieve the objective, in January 2020, the Rivers State House of Assembly passed the ‘The Rivers Contributory Health Care Program Bill 2019’ with the aim of enhancing health care delivery in the State.

The speaker of the House, Ikuinyi-Owaji Ibani explained that the bill shall further promote the interest and well-being of Rivers people and others who live and do business in the state, assuring that as the health insurance scheme is legally guided is an indication that all residents in Rivers would have access to quality health without suffering financial hardship. However, since then, nothing has been heard about the implementation of the scheme.

Efforts to reach the State Commissioner for Health, Prof. Princewill Dike, failed as several calls put to him were not responded to.

Meanwhile, some of the medical workers who spoke with The Guardian in confidence described the situation as disturbing and discouraging.

A Senior Nurse in Rivers State University Teaching Hospital, said, “Some team came here some time ago and some people registered for the health Insurance Programme, but as I speak with you, it is not functioning, Even those that registered people still pay to access health care services till now “

“Even we as medical workers, if you have a headache while on duty, you can’t access the hospital pharmacy to get a paracetamol except you pay, this is a big challenge, there is need for those who are giving medical care to others to be happy but we are not”

Also speaking, a resident Doctor in the hospital, who craved anonymity, blamed the gaps and implementation of the programme on the board in charge of health care delivery services whom he said are lacking the capacity to deliver in their responsibilities.

However, some residents in an interview said, if the scheme was functional, it would have assisted them greatly at a time the country’s economy has become unbearable.

They regretted the inability of the State Government to make the scheme functional to date.

However, further investigations revealed that there are some existing community-based health insurance programmes like the in Obio Cottage Hospital under a community base health insurance scheme managed by the Shell Petroleum Development Company ( SPDC) in Rumukrusi, PortHarcourt.

Some pregnant women, elderly, and children met at the hospital told The Guardian that they are benefiting from the scheme, stressing that it is very transparent and free.

Meanwhile, a senior Medical worker in Bori General Hospital in Gokana Local Government Area of the State said, “there is a much need to improve or expand on the access of the scheme to the citizens, government at the state level should know that proper health financing is key to achieving universal health coverage at the endpoint is what the government at the center intends to achieve”

The medical expert stressed the need to improve the quality of health services in the state and also improve on overall governance and ensure that lives are not lost because people cannot afford health care service at the time they needed it.

South Eastern states
The inability of state governors to muster the political will for its implementation, ignorance, and unwillingness of the workers to allow deductions in their monthly pay among others are responsible for the non-implementation of the NHIS for workers in the state civil service in the southeast region, several years after the scheme kicked off.

Investigations by The Guardian across states of the zone showed that no worker had benefitted from it, several years after their counterparts in the federal government have done so, even as no conscious effort is being made to resolve grey areas and institute the scheme properly in the states.

In fact, the way it is, it might take more than a political will, which might include state governments solely shouldering the burden to enlist workers into the scheme. This is because, even as many have continued to attest to the usefulness of the scheme, it is not featuring among priorities of the various state governments in the zone.

Established in 2004, the Scheme was set out to ensure that every Nigerian has access to good health care services at affordable costs for a spouse and four biological children. It was structured in a way that government contributes ten percent of the worker’s salary while the worker contributes five percent monthly to enable him get healthcare services at any designated hospital of choice when the need arises.

Enquiries in Enugu state showed that the government made an effort under the past administration of Sullivan Chime to enroll workers into the scheme by accepting a proposal to pay a whole sum that could take care of every worker in the state for one year.

It was such that at the expiration of one year, deductions would begin from the monthly pay of the workers, who would have been enrolled into the scheme. However, apparently due to limited resources, the idea was discontinued. The workers, on the other hand, did not bother about pressing for its implementation, apparently due to low pay.

Chairman, Joint Service Negotiating Council, Enugu state, Mr. Chukwuma Igbokwe, stated that attaining healthcare for all workers in the state still had a long way to go, as according to him, the willingness to do so was lacking on the part of the workers and the state government.

He, however, stated that when the bill approving NHIS was amended, the state government began a universal health coverage scheme by setting up an agency to oversee it, adding however that the challenges that bugged the national scheme were also affecting the one adopted by the state.

“We have also said that before we start it, your health facilities must be working. The primary healthcare system has to work; most people finish their health care services at the primary level; they don’t go to secondary or tertiary levels. So we must ensure that the primary health institutions are working. Apart from institutions like Parklane Hospital, which serves as primary, secondary and tertiary at the same time. You don’t just collect money from the people and at the end of the day, you don’t provide the service”, he said

Apart from this, he added that suggestions were made for the scheme to be expanded to include those in the private sector.

He added: “But the way is that once a scheme is started at the federal level and is working, each state should make it work at their level. It is working in Lagos and in the north but here; our people will want to put two and two together before doing it. They will set up a committee that will never submit their report and from there; they will begin to find a reason. Every state in Nigeria should be made to implement the NHIS, It is a good scheme and there is nothing that gives the worker joy than anytime he or she is sick, he is rushed to the hospital and he knows that his insurance covers him and his children. But when these things are not there, it makes one sad”.

An official of the State Agency for Universal Health Care told The Guardian on anonymity that they had started registering the Health Management Organizations (HMOs) that would help handle the scheme in the state.

He said that the state government was rebuilding and equipping public hospitals across the state, stressing that, he was hopeful that workers would benefit from the scheme in the shortest possible time.

“I think the government is not relenting. Part of the ongoing massive rehabilitation in the hospitals in the state is part of the effort to achieve universal health coverage. That will help lift the burden off the tertiary hospitals in the state”, he said

He said deduction would be made from salaries of participating workers to augment that percentage expected to pay by the government to fund the scheme in the state.

In Imo state, Executive Secretary of the NHIS, Dr. John Onyeokoro, said the last two years, had been groundswell preparation for the eventual full enrolment by the Imo civil and public servants into the Scheme.

According to him, the underground activities superintended over by him and supported by his workers were to ensure seamless execution of the scheme in the state in line with the enabling Act setting it up even as it cascades in the state.

In a telephone interview, Onyeokoro, told The Guardian that the scheme was waiting to finish with the dialogue with the NLC on the deduction pattern, noting that that challenge had been resolved, waiting for when the governor will soon approve of the final take-off and scale-up of the enrolment.

He said: “Deductions will commence soon from the enrollees, Civil Servants, and Public Sector workers. The governor will soon approve to scale up enrolment.

“The greatest challenge is agreeing with the labour. We have been working in the last two years,” the NHIS boss in Imo State said.

He disclosed that his office had been busy building strong Information Technology (IT), the base for the scheme, hinting that 35 data capturing machines had been assembled for simultaneous capturing of the enrollees in the 27 Local Government Areas of the state.

His words: “We have over 35 data capturing machines that could work simultaneously in the Local Government Areas. The Information Technology (IT), the platform we have is strong that it cannot be hacked.”

Onyeokoro, said arrangement for the scheme had been deepened that a new mobile technology effort to be deployed in Imo and Anambra, for the scheme, would favour it, informing that the enrollees would take the option of using recharge card in the premium payment.

A medical officer at Unizk, Awka, who spoke on condition of anonymity, said not all drugs are available, and that patients are directed to buy from outside the NHIS approved hospital.

He said some laboratory tests like X-Ray, Scan etc. are not covered in most cases under the scheme, adding that such services are charged. He added that in most cases, drug charges are inflated above the real cost outside the NHIS facility.

Corroborating to the above observation, Lady Rose Uche, a civil servant said there was an unnecessary delay while waiting for a ‘code’ clearance from the Health Medical Officer at the NHIS before one can go for a lab test. “Many are in queue waiting”, she said.

There is the Anambra State Health Insurance Agency (ASHIA) set up for civil servants in the state where the enrollee pays N2,000 per annum.

According to Chuks Dikeme, any government employee freely chooses a medical facility for accessing treatment at intervals.

He said it covers the spouse and four children on a monthly or annual deduction as insurance premium, adding that enrollees pay after treatment.

“You are free to change your medical facility anytime if not certified with their services or you changed the location of residence. Enrollee pay after treatment, but all depends on the terms of agreement with ASHIA”, he said, adding that, it was yet to take off.

In Abia State, the Scheme is yet to take off, though the government said an Executive Secretary had been appointed.

Although it was launched in September 2019, there is no framework in place to guide its operations

Permanent Secretary of the State Ministry of Health, Mr. Eze Egbulefu, said that enlistment into it was ongoing at the primary health level even as Ward Health Centers were already rendering some services.

He said the required takeoff fund which should be deducted from participating workers salaries had not been done, adding that modalities were being worked out

He said a Data Center which was the major feature of the program that would capture enlisted participants electronically had not been provided. He however disclosed that an N100 million naira take-off fund will soon be released to kick-start the program effectively.

Abuja explains
The Executive Secretary of the NHIS, Prof. Mohammed Nasir Sambo has said that the on-going reforms in the Scheme and the health insurance ecosystem in Nigeria would fast-track the collective quest to attain UHC.

He said that most of the operational, financial, and administrative bottlenecks are that had hampered the effective and efficient operation of the scheme are fast being resolved, with innovative strategies are being introduced.

Speaking at the Stakeholders workshop in Abuja, Sambo explained that as a result of various challenges, including leadership crises, NHIS was not able to provide adequate coordination and support for State Health Insurance Agencies (SSHIAS) and other stakeholders for several years which led to the adoption of various models by the SSHIAs in the design and implementation of their respective schemes, some with the support of various partners and others with none.

The NHIS boss observed that some of the reform efforts by the agency include recovery of NHIS trapped funds, reforming the financial management system of the organisation, restoring the confidence of stakeholders, and automating NHIS business processes.

He said, “Now we have a new Result Oriented NHIS, ready to reposition the health insurance ecosystem to focus on the collective drive towards the attainment of UHC.”

Sambo said the three-point rebranding agenda is anchored on restoring a value system that will transform NHIS into a credible result-driven organization; engendering transparency and accountability in the entire operations of the Scheme, and accelerating the drive towards achieving universal access to quality healthcare for all Nigerians.

He stated that for the attainment of UHC in Nigeria, which is in alignment with President Muhammadu Buhari Health Sector Next Level Agenda, NHIS enquires an effective framework for coordination, integration, and harmonization of efforts of all stakeholders in the health insurance space in Nigeria which was the basis of the concept of Health Insurance Under One Roof (HIUOR).

Sambo recalled that Health Insurance Under One Roof has been widely discussed by State Health Insurance /Contributory Agencies across the nation, the NHIS, development partners, and Civil Society Organisations (CSOs) among other stakeholders.

He said that a memo was presented at the 58th Emergency National Council on Health on decentralizing health insurance implementation in Nigeria to States and it was unanimously adopted adding that this important health financing reform using legislation at the state level to drive mandatory health insurance, led to the establishment of State Social Health Insurance Agencies (SSHIAs).

Also speaking, the Chairman, Forum of Chief Executive Officers of State Health Insurance Agencies ((SSHIAS), Dr. Adeniyi Oginni, said that in 2015 a memo of the Minister of Health was presented to the National Council on Health seeking to formally notify Council of the development of Implementation Guidelines for State Supported Health Insurance Schemes (SSHIS), towards the achievement of UHC in Nigeria and the need for States to adopt and implement the Schemes.

According to him, the memo encouraged States to adopt and implement this policy using opportunities presented by the National Health Act 2014 and SOML while in 2017 an update was presented to the National Council on Health regarding the progress towards establishing SSHIASs, and the council was invited to approve the adoption of SSHI policy by states as the most cost-effective and sustainable option of providing their citizens access to good quality healthcare and achieving their health system goals.

Oginni noted that the policy encouraged the state to commence processes aimed at setting up their health insurance agencies and implementing this policy of decentralization of NHIS but only a few states of the federation bought into this new policy until the appropriation of the Basic Health Care Provision Fund (BHCPF) established by section 11 of the National Health Act, 2014 by the National Assembly in 2018.

He said: “Since the pre-requisite for accessing the BHCPF among other things include the setting up of a functional SSHIA, between 2018 and now all other states except two now have a SSHIA albeit at different levels of establishments. Each state SHIS has its own laws and operational modalities and had started to record impressive success in coverage rate as at the beginning of this year, 2020 when the leadership of NHIS, recognizing the poor coordination and regulation of the industry came up with the policy of HIUOR which was a welcome development in the industry. A workshop of critical stakeholders was conducted at Nassarawa state at which a framework was designed and adopted by all and a Technical Working Group set up to develop a policy document to reflect the operations of the HIUOR policy in Nigeria.”