Amid soaring cost, affordable healthcare still elusive in states

The National Health Insurance Scheme (NHIS), established by the Federal Government under Act 35 of 1999, was set up with the objective of making healthcare accessible and affordable to millions of Nigerians. In simple terms, the scheme was established to make healthcare available to Nigerians at an affordable cost by sharing, or covering the expenses associated with healthcare of individuals.

The scheme is broken into three different programmes all aimed at addressing the health needs of different segments of the society. The first programme being the Formal Sector Social Health Insurance Programme covers the federal, state and local governments, as well as the organised private sector. This programme also covers other uniformed services and students of tertiary institutions, including the military and para-military services.

The other two are the Informal Sector Social Health Insurance Programme, and the Voluntary Contributors Social Health Insurance Programme. The third programme covers pregnant women, children under five years, prison inmates, internally displaced persons, physically challenged persons, refugees, victims of human trafficking, and immigrants.

Since it debuted about 10 years ago, the NHIS has stuttered badly with only an infinitesimal percentage of Nigerians (just about five per cent) captured by the scheme. In fact, the gross failure of the scheme finds expression in the fact that most Nigerians are still incapable of getting quality healthcare at affordable prices even as many others are still paying out of their pocket for medical expenses, a development, which is seen to be inimical to the attainment of good health.

According to experts, several factors have been responsible for the NHIS’ apparent failure. Prominent among them are poor government funding of healthcare and the NHIS; inadequate legal framework for a successful scheme; optional enrollment policy; poor implementation of the Act, inappropriate practices by the regulatory agency, the health maintenance organisations (HMOs) and the providers, as well as, sheer lack of political will.

Hobbled at the national level by a cocktail of distressing factors, only a few states have made or indicated interest to follow the Federal Government’s step by setting up health insurance schemes in their domains.

Clearly, the ineffectiveness of the NHIS and the failure of state governments to have up and running health schemes has seen a groundswell of Nigerians get detained in medical facilities for their inability to pay for medical services rendered, or die of minor ailments, which ought to have been treated if there were government-sponsored healthcare packages in place.

For instance, Busayo Busari and her new-born daughter Fikayo were detained at the Lagos University Teaching Hospital (LUTH), Idi-Araba, Surulere, Lagos, for four months over unpaid bills, after Busayo was delivered of her baby through Caesarean section in February 2018.

After spending about a month at the hospital, Busari’s medical bill rose to N387, 000, and some social workers there assisted her to raise funds to defray part of the bill, a development, which left her with N93, 000, which was eventually underwritten by good Samaritans.

In the same vein, Mr. and Mrs. Godwin Ehi-Ebhodaghe, an unemployed father and his petty trader wife recently heaved a sigh of relief when help came to their son from the blues, after he was diagnosed with of Subdural Empyema.
Subdural empyema is a collection of stored pus in the subdural space, which is located between the surface of the brain and the covering over the brain, both on the right and left side called the dural.

So, when God Is Great Ebhodaghe, 16, was diagnosed with it after a tour of several hospitals, the initial deposit for the needed operation to be carried out at Lagoon Hospitals, Apapa, Lagos was N3.5m.

With no employment, no participation in any health insurance scheme, and with health workers in federal and state medical centres on strike at that time, the world came crashing on the Ebhodaghes. But the entire staff members of Lagoon Hospital and its management pulled resources together and the complex surgery was successfully carried out on May 22.

Last week, management of the University of Benin Teaching Hospital (UBTH), Edo State, explained that waivers to the tune of N50m have so far been granted indigent patients, particularly those with neurosurgical, orthopaedic, paediatrics, obstetrics, and gynaecological cases in the hospital. Neurosurgical and orthopaedic cases incurred the highest debts as a result of their lengthy stay in the hospital.

The Chief Medical Director of the hospital, Prof. Darlington Obaseki, who made the disclosure during an interactive session with staff members as part of activities to mark his first year in office, said that corporate bodies were encouraged to assist patients who suffered from financial difficulties.

Obaseki said: “For this year (2018) alone, we have already cleared about N50m. Many of the patients came unprepared because they were mostly accident cases,” he said.

The CMD, who said that even though corporate bodies were encouraged to assist patients with difficulties, UBTH had inaugurated an indigent patients committee to raise voluntary donations, adding that the health insurance scheme, which the state government has proposed would promote affordable healthcare for the residents.

“The state government is thinking about a health insurance scheme. So, when the health insurance scheme comes on stream, I think that medical debts will be a thing of the past.”

While many attribute the political will demonstrated by ex-President Olusegun Obasanjo in 2005 as being responsible for the operationalization of the NHIS with the enrollment of the federal civil servants after many failed attempts to kick-start the scheme by previous administrations, the same cannot be said of state governors, who have continued to look the other way while the less-fancied practice of citizens paying for medicare from their pockets continues to hold sway in most states.

The colossal failure recorded by the NHIS must have triggered the lethargy being experienced at the state level. To date, less than 10 of the 36 states have indicated interest to commence health insurance schemes, just about five have taken the bull by the horn even though a good number of them are neither here nor there.

A senior registrar in the Department of Community Health, LUTH, Dr. Odusolu Yetunde, while deploring the fact that only five per cent of Nigerians are currently on board the NHIS said, “many states are yet to launch their schemes because their chief executives lack the political will to ensure their takeoff, while some blame it on paucity of funds even when the one per cent consolidated health fund is yet to be fully implemented and acted upon.

“Another major reason why state governments do not have health insurance scheme in place is because health is not in their primary agenda, as they fail to see the relationship between health and development,” she stated.

On what states stand to gain by operationalising health insurance schemes for their people, she said, “Firstly, it will help to lower the indices of morbidity (disease) and mortality (death) in the states, as well as, help in reducing our overall national indices on morbidity and mortality.

Secondly, it would help to reduce out of pocket payments by citizens when they are sick, just as it would grant them access to health services faster in situations, where they could have been encumbered by funds.

“Thirdly, health insurance schemes help to promote a healthy workforce, which ultimately translates to development of the state. It also helps to increase the GDP of the state, as a healthy person will be more productive at work. The mortality that it helps to reduce could be expanded such as infant mortality rate, maternal mortality rate and Under-five mortality rate etc. The Abuja Declaration of Health by African countries set a target of allocating at least 15 per cent of their annual budgets to health in order to improve the health sector, yet the Nigeria expenditure on health is very low, with health getting less than five per cent of this year’s annual budget. This contributes to the low health status of Nigerians.

“The NHIS is a good financing option for healthcare because it will address the issue of universal health coverage. Also, it helps to protect from financial catastrophe or hardship when people have to pay for health services.

Consultant Ophthalmologist and Head of Department, Guinness Eye Centre at LUTH, Prof. Adeola Onakoya,
Is of the opinion that if states are not ready to adequately fund the process, there is no way they can operate effective health insurance schemes for their workers and other residents.

“The economic power of a nation is really the age groups that are being afflicted by all these diseases that constitute public health problems. Take for instance, high blood pressure and diabetes, sufferers of this health challenges are in their late 30s, early 40s, and 50s. All these people are people that are yet to get to age of retirement, hence the form part of the economic powerhouse of a state. Unfortunately, this time is usually the time where many health disorders ravage the people,” she said.

Onakoya advised that, “If the states, invest in health insurance schemes, it would effectively fund health at primary care level, where a lot of awareness would be created and people would have access to health centres that would be properly funded. Even drugs would be made available at general hospitals through these schemes. I think the state stands to gain a lot because if they pay insurance for their workers, then they would have healthy workers in their employ.”

National President, Healthcare Providers’ Association of Nigeria, Dr. Umar Oluwole Sanda, sees health insurance scheme as a way of saving for the rainy day, as well as a way of eliminating out-of-pocket payments for health, which is the way to go, as most developed countries started it many years ago.

Narrowing it to a state like Lagos, he said, “The population of Lagos is large and more people are coming in, therefore, government alone cannot provide for the health needs of all these people. So, by introducing a health insurance scheme, which is contributory, it will increase access, quality to healthcare, as well as, eliminate quackery.

“There are so many models of health insurance. The model we are trying to use here is the contributory, as resources are being put together. Look at primary care for instance, the government cannot do it alone considering the fact that its facilities alone cannot cater for the needs and demands.

“But the way Lagos State is going about it, it is being overdressed. The state knows all the private hospitals that have registered with it, and majority of the health facilities are competent enough to handle primary care and if they really want to, they can engage all of them at a go and not discriminate.

As it prepares to takeoff, he suggested that the state government should do a lot of sensitisation “because many people once they hear the word insurance, they are always afraid to register, and the mandatory aspect of it that if you do not have health insurance, you cannot do anything with government would make it better accepted.

He stressed the need for the interest of healthcare providers to be well protected, saying they must be carried along because neglecting them would be the beginning of the failure of the scheme, especially as they are the bedrock of the scheme.

“I do not know why Lagos State is foot-dragging, as other states that have promulgated laws to back their health insurance scheme have started in a little way. Lagos can start in a little way and grow it from there.

Bayelsa Ahead Of Others In Health Insurance scheme
Perhaps, one of the most laudable legacies of the Governor Henry Seriake Dickson-led administration in the sector will the successes recorded in the Bayelsa Health Insurance Scheme (BHIS), where over 110, 000 public sector enrollees have so far signed up. Advocacy is presently going on to bring in private sector participation.

The BHIS commenced for the state’s workforce in June 2017 with a plan to subsequently extend it to cover the informal sector. The encouraging feedback has been overwhelming, making it a model for other states to follow.

The Guardian checks revealed that most public and private hospitals in the state are taking full advantage of the development to register their hospitals in the scheme.

Civil servants, who were skeptical of the scheme, have now been won over by the testimonies of those, who have benefitted from it. Despite the growing number of enrollees, the state government has been able to meet its financial obligations to healthcare providers.

The formal inauguration of the BHIS last year was preceded by the commencement of the yearly free medical examination for civil servants, political appointees, first class traditional rulers and other senior ‎citizens in the state at state-owned health institution.

According to the Executive Secretary of BHIS, Zuoboemi Agadah, the success so far recorded in the scheme is as a result of the adoption of the template already put in place by the NHIS.

He described the BHIS as a social health insurance scheme, where there is social solidarity and risk equalisation, such that you don’t pay or subscribe to it and pay premium with consideration of your health risk.

“We bring everybody to the same spot and the same level and then treat them. It’s more or less paying according to your ability, and the monies are pulled into one pool, from where we use it to buy drugs and care for those that need care at every point in time.”

Agadah insisted that the successes recorded in the scheme was as a “result of commitment, both at the level of the operators and policy makers, who thought it would be nice at this point in time to bring a system like this to take care of the health needs of Bayelsans. So, we started with the civil servants and we are almost done with the civil servants and we are setting up modalities for the private sectors and the general public. We have started building in-roads into them now with advocacy. That is where we are, and I think it’s most especially the state government’s commitment and those that are given the responsibility to carry out the system.”

He added that both public and private sectors, as many that comes, we are not discriminating as long as you meet our standard for accreditation we will accredit you, because we know that the population pool is large so we want as many hospitals available to come so they can participate. We don’t want to select a few and then over flog those with so many people and then we start having problems of care. So there is that competitiveness and there is that openness also.

Ayade Care Yet To Steady Flight After ‘Takeoff’
The Cross River State government’s free “Health Insurance Scheme” better known as “Ayade Care” was launched in 2016 to provide good and affordable healthcare services to the people. But since being unfolded, the scheme is yet to formally off as labour unions in the state are still resisting it.

Governor Ben Ayade, while signing the enabling bill into law, described the free health insurance scheme specifically targeting the less privileged as “a brother lending a hand to another brother with all of us standing for all of us…”

Commenting on the scheme, the maiden Director General of Cross River State Primary Healthcare Development Agency, Dr. Betta Edu, said, “the target from all the sources is that every month, at least we should have a billion naira put into healthcare from 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 would not be able to provide the level of healthcare that the government is thinking about, as “government will equally be investing money in the scheme 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 collaboration between a whole lot of stakeholders and as such, transparency, accountability remains the watchword. The World Bank will not want to put its money in an insurance scheme that is a fraud and it has a criteria that this insurance must go through and fit in.”

Edu added: “Given the present economic downturn, people can longer afford to pay for their health bills. You have people come down with lots of diseases and cannot afford to buy drugs, you have women that are pregnant and cannot access quality health services because they cannot afford it … so, this healthcare insurance scheme 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 an income to pay for this insurance scheme.

The Nigeria Labour Congress in the state at the programme’s launch insisted that before labour accepts the N1, 000 compulsory deduction for the programme, the state government must implement outstanding workers’ promotion. In fact, the “no promotion, no deduction” posture of the labour union is what has left Ayade Care gasping for breath and unable to fully fly.

Responding, Edu said: “We have been having discussions with labour and it will continue. As a state we need the workforce and the labour union to buy into the state health insurance scheme.”

Financial Constraints Hinders Scheme’s Takeoff In Akwa Ibom
Once the state’s finances improve, Akwa Ibom State government said it would give prompt attention to the health insurance scheme, which is currently on the front burner.

Commissioner for Health, Dr. Dominic Ukpong, told The Guardian that following the importance that Governor Udom Emmanuel attaches to the scheme, the state House of Assembly has already passed the scheme’s bill, which is awaiting the governor’s assent.

“Our governor knows this; the legislative house knows it too, and that is why it passed a bill to that effect, which is awaiting the governor’s assent. Once it is assented to, the implementation will commence because there are many advantages to having a scheme like this in place.

“Apart from the direct advantage it confers on a ‘common person,’ we also stand to gain from the international community as partners, but the actual implementation of this scheme requires a lot of financial commitment,” he noted.

Ukpong lamented that the state was under huge financial constraint as a result of the Federal Government’s non-commitment to refunding money used by the state to carry out federal projects, as well as, dwindling resources.

He equally informed that the state was seriously considering liaising with corporate bodies to get assistance in he implementation of the scheme.

“We also intend to make it mandatory for every employer to insure his/her employees. The problem that is holding the implementation of the scheme is the money to run it, we can get volunteers, well meaning individuals, to help fund it, because if the governor signs it into law now and there are no funds to fund it, its becomes a problem.

“We are going to have a meeting with our counterparts in states that are already implementing it so as to discuss how they get financial support, see if we can borrow from what they are doing or what they have done, he said.

Rivers Committed To Implementing Health Insurance Scheme
A short while ago, the state Commissioner for Health, Prof. Princewill Chike, restated government’s commitment to implementing the Health Insurance Scheme, which bill is still before the state Assembly.

According to him, the government was already building five zonal hospitals as part of the preparations for the project takeoff,
adding that the Braithwaite Memorial Specialist Hospital (BSMH) was also being upgraded to meet the requirements for the scheme.

Chike explained that government’s intention for the scheme was to make healthcare affordable and accessible to the ordinary people, even as the scheme would reduce out-of-pocket expenses on healthcare.

“The health insurance scheme is a good thing; it covers a wide spectrum of aliments; all you need to present is your card…What is required to access the scheme will be made affordable; it is a scheme that targets the ordinary people,’’ he said.

The commissioner added that the state government was carefully packaging the scheme to ensure that challenges witnessed in similar schemes elsewhere would be eliminated.

Immediate past Chairman of the Nigeria Medical Association (NMA) Rivers State Chapter, Dr. Datonye Alasie, while shedding light on the proposed scheme in the state said a lot of stakeholders’ engagements and consultations have been carried out already. So, it is expected that once the bill is signed into law, an agency would be created, which is the Rivers State Health protection Agency that will manage the process of the state-wide contributory health insurance scheme, even though there are some existing community-based insurance programmes which are small.

Alasie, who expressed hope that there would be more up-take in the health insurance scheme both in the formal and informal sector when the scheme gets underway, said the scheme would also facilitate the achievement of universal health coverage.

“The expectation is that many citizens would be enrolled into this health protection programme and they would contribute to it, which would help generate more revenue, guarantee access to health care. This can help 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 healthcare services when they need it.

Kano Learning From NHIS’ Mistakes
In order not to wobble, Kano State is learning from the mistakes of the NHIS as it begins to roll out packages in its health insurance scheme.

Executive Secretary of Kano State Contributory Healthcare Management Agency, Dr. Halima Muhammad Minjiyawa, said the newly inaugurated health scheme aims to provide access to qualitative and affordable healthcare delivery to all residents of the state.

Segmented to take care of formal and informal sector players, as well as the vulnerable group, Dr. Minjiyawa said, “for now, the agency is just focusing on the formal sector, and we are basically dealing with the civil servants at the state and local government levels. Contributions into the scheme are deducted from their pay roll and the amount per enrollee is based on their grade levels.

She hinted that the agency is engaging all state-owned secondary health facilities, 133 primary care centres and 40 private facilities, adding that enrollees are advised to choose primary healthcare centres close to them to ease of treating cases like malaria, typhoid, pneumonia and similar cases. For beneficiaries willing to see specialists like pediatricians, gynecologists, and the likes, they would be referred to one of the secondary facilities in our enrolment. Let me say that all our healthcare facilities are only considered after passing the accreditation test of the NHIS,” she noted.

“ I must state that we are still learning from the mistakes of NHIS. For instance, NHIS engages NMOs for payment, we don’t engage HMO’s for payments having noticed a huge challenge when it comes to making payment to health providers from the HMOs. So, for in Kano, the agency pays directly to health facilities participating… Before we started, we embarked on sensitisation programme, we educated all and sundry including labour unions, senior civil servants, and went to all the 44 council areas to educate everyone on the benefit of the programme. Yes people are skeptical, but they also understand how costly out-of-pocket payment on health matters cost. We will continue the sensitisation and awareness creation about the scheme.”

The following month after Kano kicked off its insurance scheme, Kwara State flagged its off, with the governor, Abdulfatah Ahmed urging citizens and residents to register and take advantage of the scheme.

The Kwara Health Insurance Scheme (KHIS) replaces the State Community Health Insurance scheme, and its major goal is to provide quality, accessible and affordable healthcare to citizens and residents alike for a low annual premium.

Ahmed at the official launch said the scheme’s establishment was a reflection of his administration’s commitment to the health and well-being of people of the state.

“Thanks to its low, affordable premium and associated quality healthcare, the Kwara State Health Insurance Scheme takes us closer to our dream of universal healthcare for our people.”

The state government, he added will boost the scheme with 40 per cent of funds received through the “Saving One Million Lives Performance for Results Initiative,” a programme of the Federal Ministry of Health, supported by the World Bank and targeted at improving maternal and child health in the country.

Even though Ahmed pledged that, “no more will citizens and residents of Kwara State be unable to access critical treatment because they cannot afford to pay hospital fees or buy prescribed drugs,” not much has been heard of the scheme since its launch.