Why over 4.5 billion people worldwide, 190 million Nigerians don’t have access to health services

Ahead of World Health Day 2024, tomorrow, April 7, the World Health Organisation (WHO) has warned that Nigeria and so many other developing countries may not be able to meet the 2030 target for Universal Health Coverage (UHC), because the right to health of millions is increasingly coming under threat.

The WHO, in a statement, said diseases and disasters loom large owing to death and disability. “Conflicts are devastating lives, causing death, pain, hunger and psychological distress.

“The burning of fossil fuels is simultaneously driving the climate crisis and taking away our right to breathe clean air, with indoor and outdoor air pollution claiming a life every five seconds,” it noted.

The WHO Council on the Economics of Health for All has found that at least 140 countries recognise health as a human right in their constitution. “Yet countries are not passing and putting into practice laws to ensure their populations are entitled to access health services. This underpins the fact that at least 4.5 billion people — more than half of the world’s population — were not fully covered by essential health services,” it noted.

To address these types of challenges, the theme for World Health Day 2024 is ‘My health, my right’.

This year’s theme was chosen to champion the right of everyone, everywhere to have access to quality health services, education and information, as well as safe drinking water, clean air, good nutrition, quality housing, decent working and environmental conditions, and freedom from discrimination.

Meanwhile, recent estimates, which are corroborated by the House of Representatives Committees on Insurance and Actuarial Matters and Healthcare Services, reveal that 26 years after the establishment of health insurance in Nigeria, not more than 10 million Nigerians have any form of health insurance. It also shows that about five million of the numbers are civil servants. This shows that over 190 million Nigerians do not have health insurance.

According to WHO, Nigeria has the highest out-of-pocket expenditure on health in West Africa and many Nigerians are falling into poverty due to ill health.

Statistics from the global health body showed that out-of-pocket health expenditures account for more than 70 per cent of overall health spending in Nigeria and in 2020; the country’s out-of-pocket expenditure was 74.7 per cent.

A survey by NOI Polls shows health insurance remains a mirage as 80 per cent of Nigerians still pay out-of-pocket.

The Guardian’s investigation revealed the implementation of the scheme had been mired with corruption, lack of transparency and accountability, irregularities among HMOs and ill-treatment of enrollees by healthcare providers.

It also showed the programme has been fraught with poor service delivery by the HMOs as well as low-quality services on the part of the healthcare service providers, as evidenced by the high level of dissatisfaction amongst enrollees who are thus discouraged from recommending the scheme to potential subscribers.

The Guardian gathered that in some hospitals, the pharmacy for patients covered by the NHIA is separate from the hospital’s main pharmacy, and is allegedly stocked with low-quality drugs, as against the main.

It was gathered that owing to inflation, the capitation paid monthly by HMOs to retainer hospitals is so insignificant to carter for the cost of treatment and needs urgent upward review. Several years ago, the capitation used to be minimum of N500 per patient monthly for the cheapest plan. It was later reviewed to N750, which is still insignificant considering the current economic realities.

Also, there are reports that funds meant for the implementation of the national health insurance policy are being mismanaged, as well as allegations that some HMOs fail to remit funds or pay monthly capitation to the healthcare providers.

Nigeria had in 1999 established a national health insurance scheme (NHIS) with the sole aim of providing pre-paid accessible and affordable quality health care to the population of 200 million, thereby meeting Universal Health Coverage (UHC).

Unfortunately, 25 years after, over 190 million Nigerians do not have any form of health insurance despite huge investment by the Government and the upgrade of NHIS to an agency, National Health Insurance Authority (NHIA), in 2022, to make it mandatory and enlarge its scope.

The Guardian investigation revealed that most Nigerians are discouraged from enrolling into the programme owing to many challenges accessing care such as long waiting hours, substandard services and drugs, and inhuman treatment at provider hospitals.

The investigation identified corruption, irregularities, inadequate funds and human resources for health, political interference, and irregularities among other challenges.

Indeed, the idea of health insurance in Nigeria was conceptualised in 1999 by former President Olusegun Obasanjo through establishment of the NHIS. The scheme was officially launched on June 6, 2005, and services to enrollees started later in 2005. To make the plan mandatory and more functional, the NHIS was upgraded to the National Insurance Authority (NHIA), in 2022, through the signing into law of the NHIA Act by the immediate past President, Muhammad Buhari.

The NHIA is the regulator and implementer of health insurance programmes in Nigeria. They accredit and register the Health Management Organisations (HMOs) and provider hospitals. The enrollees buy a health insurance plan with the HMOs and choose a retainer/provider hospital to attend. The enrollee or the employer who bought the health insurance plan pays a premium every year to the HMO. The HMO in turn pays the retainer hospital a capitation of N750 monthly for each patient.

Many Challenges Of Implementing NHIA
The HMOs also have their complaints. “Most of the primary providers do not have the recommended 2,500 enrollees/lives and are running at a loss, which is responsible for the many challenges faced by the enrollees like waiting for long hours to access care and being treated as lepers. The actuarial recommendation for risk management for the primary providers was that with a capitation of N750 paid for each patient per month, they would have N1.87 million pool to work with every month. Unfortunately, most primary provider do not have that number and are running at a loss,” said National Publicity Secretary, Health and Managed Care Association of Nigeria (HMCAN), Mr. Lekan Ewenla, told The Guardian. HMCAN is the coordinating body of registered HMOs in Nigeria.

Ewenla said the HMOs are accredited for the secondary and tertiary facilities like the general hospitals, teaching hospitals and most private hospitals. He said it is recommended that an HMO will have minimum of 300,000 enrollees/lives. This means that with the capitation of N750, they will have N22.5 million monthly to work with.

Ewenla said the NHIA should limit the functions of the primary providers, since their scope is limited.

Ewenla said some of the challenges faced by HMOs in Nigeria include inadequate funding/capitalisation, delayed premium payments, fraud and unethical practices, regulatory challenges, operational inefficiencies, limited skilled workforce and inadequate infrastructure.

According to International Health Management Services Limited (IHMSL), many HMOs suffer from a lack of adequate capital to maintain their operations and pay for medical services.

Also, a provider hospital, Optimal Specialist Hospital, Gbaja Street, Surulere, Lagos, said HMOs are owing the hospital over N22 million. The Medical Director and Consultant Obstetrician and Gynaecologist, Dr. Celestine Ugochukwu, said: “There are so many issues. How do you expect us to attend to enrollees when the HMOs, they are registered with, are owing us over N22 million with no commitment to pay?”

Assessing the level of level of implementation of the NHIA Act, a Fiscal Policy expert and the Lead Director, Centre for Social Justice, Eze Onyekpere told The Guardian that not much has changed one year after the enactment of the NHIA Act.

Onyekpere argued that less than 10 per cent of Nigerians have health insurance, adding that there is still more talk and less action.

“The states have enacted relevant laws, but they are yet to match the talk with the work by dedicating one per cent of their consolidated revenue fund to health. Instead of voting money for the illegal and un- constitutional office of the First Lady, FGN should vote money to activate the fund, the way forward is to garner the political will to prioritise health,” Onyekpere said.

Interestingly some states, especially Delta, Lagos and Kwara are making giant strides their mandatory contributory and social health insurance programmes.

House Of Reps, Others Intervene
Little wonder, the House of Representatives has mandated its Committees on Insurance and Actuarial Matters and Healthcare Services to investigate the NHIA, following allegations of mismanagement of funds and other irregularities in agency.

The House had, last month, adopted of a motion by Hon Esosa Iyawe on “Alleged Mismanagement of Funds and Other Irregularities in the Operations of the NHIA,” at plenary.

The House said that the investigation was aimed at making relevant interventions in the agency to ensure effective implementation of the National Health Insurance Policy.

Hon Iyawe, in the motion, explained that the Federal Government in pursuit of the Health Insurance Policy has made several budgetary allocations under the management of the NHIA and some HMOs.

He, however, expressed concerns that that despite the huge budgetary allocations to the Health Insurance Scheme, available records show that “only a negligible three per cent of persons in the formal sector have access to health insurance, leaving over 170 million Nigerians without Health Insurance.

“26 years after the programme commenced, reports have shown that, out of a population of about 200 million, only about four million Nigerians are covered under the scheme, which is contrary to the claim by the Authority that over 10 million Nigerians are currently enrolled in the programme.”

Meanwhile, the World Health Day also marks the creation of the WHO as a whole. In December 1945, officials of Brazil and China proposed the creation of an international health organisation, that is all-encompassing and absolutely independent from any government powers.

Half a year later, in New York, in July 1946, the constitution of the WHO was approved. Said constitution entered into force on April 7, 1948, as 61 countries signed in agreement for the inception of the Non Governmental Organisation (NGO).

As one of the first official acts of WHO; they created the celebration of World Health Day. It was first observed on July 22, 1949, but the date was later changed to April 7, the establishment of WHO, to encourage student participation.

Since 1950, the Worth Health Day uses a different theme and theme each year selected by the current WHO Director-General, based on the suggestions of the member governments and staff.

World Health Day provides a global opportunity to focus attention on important public health issues that affect the international community. On the occasion of World Health Day, promotional programmes are launched that continue for a long time after April 7.