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NHIS: Poor implementation threatens health care

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Cover-NHIS-HospitalThe National Health Insurance Scheme (NHIS) is a body set up under Act 35 of 1999 by the Federal Government, to improve the health of all Nigerians at an affordable cost through various prepayment systems.

Globally, health insurance is a social security system that guarantees the provision of health services to persons on the payment of toke at regular intervals.In Nigeria, the NHIS was officially launched in 2005 by former President Olusegun Obasanjo, with a mandate to enlist at least 70 per cent of Nigerians by the end of 2010. The goal post was later shifted by the last administration to cover at least 30 per cent of Nigerians, by the end of 2015.

Unfortunately, 11 years after the scheme took off, only about four per cent of Nigerians, mainly those in the formal sector (civil servants), are on the scheme.According to the Act establishing the scheme, it is supposed to encompass government employees, the organised private sector and the informal sector. It also covers children under five, permanently disabled persons and prison inmates.

In the current scheme, contributions for NHIS are earnings-related. The employer pays 10 per cent while the employee pays five per cent, representing 15 per cent of the employee’s basic salary. However, the employer may decide to pay the entire contribution. The contributions paid cover healthcare benefits for the employee, a spouse and four biological children below the age of 18 years. More dependents or a child above the age of 18 could be covered on the payment of additional contributions by the principal beneficiary.

But The Guardian investigation revealed that most Nigerians are still paying out-of-pocket for medical services. With the gloomy economic situation in the country, it is so bad that many Nigerians cannot afford going to hospitals. They rather patronise quacks and roadside drug vendors. Even in some states where healthcare is free for the elderly, pregnant women and children under-five, many complain of not having enough money for transport and other logistics.

The Guardian reliably gathered that the civil servants have resisted remitting their own part of the counterpart payment to the NHIS, thereby frustrating the scheme. It was further gathered that the major challenged being faced by the NHIS towards universal coverage, is that the scheme is optional. People can just decide not to buy into it. However, the NHIS had in the last political dispensation sent a draft bill to the National Assembly requesting that the scheme be made mandatory. The NHIS Governing Council amended the Act to transform it into an agency with regulatory powers to make the scheme compulsory. But the bill was not passed.

It is believed that for the NHIS to regulate all the various fields, either in the social health insurance, or the private or vulnerable groups; it cannot just be a scheme, it has to be an agency that is going to look like an authority that can monitor various schemes in the country that are to be established.

Another major challenge confronting the scheme is that some stakeholders, especially pharmacists under the aegis of the Pharmaceutical Association of Nigeria (PSN), are not happy with the capitation method of payment.

Capitation is payment, which the client makes on a regular basis (usually monthly) to the provider – a clinic or a hospital – and started with N550 monthly but is supposed to be renewed every year.

The pharmacists accuse the NHIS of allowing medical doctors to hijack the scheme and determine what other professionals get in the bounty.Investigation also revealed that some of the Health Maintenance Organisations (HMOs) do not pay the retainer hospitals as and at when due. Some of the retainer hospitals do not give the patients the best services because they are either being owned by the HMOs or do not have the capacity to provide the services they promised.

HMOs are designed to deliver quality health care to a designated population in a cost effective manner, through health care providers, who are paid either a fixed budget or discounted fees. They use a value-driven system of managed care to provide affordable health services

The financial burden of risks of over-using health services are borne by the HMOs, its service providers or a combination. There are various explicit and implicit rules that govern the risk sharing. The member must receive health care from HMO-approved provider.

HMOs have exclusive provider networks. They may also use primary care providers (PCP) as gatekeepers. Gatekeepers are responsible for arranging a patient’s referral to a specialist or admission to a hospital.While most HMOs use gatekeepers, some HMOs have open access plans. These plans allow the patient to choose any PCP or specialist in the network without a referral.

Many HMOs also use reimbursement systems to encourage providers to be more cost conscious. HMOs may contract directly with physicians in the community, or may contract with networks of physicians. This arrangement is called a network or IPA model HMO

HMOs may have their own physicians on salary or in an exclusive contractual arrangement. This is called a group-model or staff-model HMO.One of the cardinal responsibilities of the NHIS is the maintenance of the highest standards with regards to quality of care that comes with respect for the rights and dignity of enrollees.

To address the shortcomings of some HMOs, the NHIS had in September 2014, reaccredited 39 HMOs after what it described as a thorough process of revalidating the health care organisations.

Another major challenge of the NHIS is the three-tier system of government, because what obtains at the federal level is not necessarily accepted in the states. The Guardian found that only few states have bought into the Scheme and even in those states, it is only the state employees that are on but not the local government employees. It was also gathered that the Federal Government is paying its contribution for its employees but the state governments are not. The first two states that bought into the Scheme before 2012 were, Cross River and Bauchi, but they suspended it along the line and mostly the complaints were the inability to pay the contribution for workers of the state.

Other states such as Delta and Lagos have set up laws establishing the State Health Insurance Scheme. Delta state has established the Delta State Contributory Health Commission (DSCHC).The economic meltdown has equally affected the implementation of the scheme, as many Nigerians have refused to buy into the scheme.

The distribution of medical facilities, in the country is another challenge. The way the facilities are distributed is questionable. Over 90 per cent of the country’s disease-burdens are in the rural areas, but less than 10 per cent of the facilities are in the rural areas.

Many of the qualified human resources are not ready to move to the rural areas, because of lack of infrastructure such as schools for children, potable water, electricity and others.

The Scheme also lacks public awareness. Enough awareness has not been created to enable many Nigerians to benefit from the Scheme.As part of efforts to increase coverage, the NHIS, in August 2014, rolled out the National Mobile Health Insurance Programme (NMHIP). The programme was in collaboration with a cross section of stakeholders, including Salt & Einstein MTS Limited as Mobile Technology Aggregator, the Mobile Network Operators (MNOs), the National Communications Commission (NCC), HMO and Healthcare Facilities (HCF).

Mobile Health Insurance is a platform for the application of information technology in the operations of the NHIS, and it involves automatic online registration including choice of HCFs and HMOs

Unfortunately, despite all these efforts, most Nigerians still pay-out-of-pocket for health services.Recently, the Healthcare Providers Association of Nigeria (HCPAN) raised the red flag over the failure of governments to enable the NHIS meet its mandate of ensuring that all Nigerians have access to pre-paid, cheap, accessible and quality health care.

It is feared that the situation may not get better because the Federal Government is yet to start full implementation of the National Health Act (NHA) 2014 that recommends that at least one percent of the Consolidated National Fund (CNF) should be set aside yearly for NHIS and Primary Health Care (PHC) services.

The fund is estimated to be N60 billion. But The Guardian learnt that there is not such provision in the current national budget. It was also found that there is a dropped in the budgetary allocation for health from average of about 5.5 per cent in the last 10 years to about 3.7 per cent.


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