NHIS Policy: Time for Universal Coverage?

Nigeria is one of the most populous countries in the world. By October 31, 2011, the United Nations estimated the population to be about 167 million. Located in the West African tropical region, the country also has a high burden of disease and inequity. According to the Ministry of Health, about 60% of health expenditure is out of pocket, health expenditures in 1999 were about 4% of the national budget. In order to provide equitable access to healthcare delivery in Nigeria, the Federal Government of Nigeria introduced a National Health Insurance Scheme.


The National Health Challenge

The health indices of Nigeria have been unenviable. According to the 1999 National Demographic Health Survey, the infant mortality rate was 75 per 1000; childhood vaccination was 17%; only 42% of births were attended to by skilled health workers¹. A 1999 Multi Indicator Cluster Survey by the Federal Office of Statistics estimated a maternal mortality ratio (MMR) of 704 deaths per 100,000 live births for a period of six to twelve years preceding the survey. 
According to UNAIDS/WHO Epidemiological Fact Sheet 2004, the 1999 HIV prevalence in Nigeria was 5.4; about 3.1 million new infections occured that year and 16,188 AIDS cases were reported. Nigeria also has one of the highest malaria and tuberculosis burden in the world. Average life expectancy was 47 years for males and 49 for females. The Nigerian health system ranked 187th out of 191countries in WHO global health rankings released in 2000. 


The National Health Insurance Scheme (NHIS) Policy
This policy was enacted by Act 35 of 1999. It is officially organized into six Social Health Insurance Programs (SHIPs): formal sector, urban self-employed, rural community, children under-five, permanently disabled persons and prison inmates. Of the six programs, the formal sector SHIP is the only one that is currently operational, and is available to both public and private organizations of ten (10) or more employees.
Under the Formal Sector SHIP, organizations register with the NHIS and are required to affiliate themselves with a particular health management organization (HMO). Each employee then registers oneself, plus up to 4 dependents, with a particular primary care provider. Contributions towards the insurance program are earnings-based and equal to 15% of a member's salary. Of the contributions paid, two-third (10%) is covered by the employer and one-third (5%) is paid by the employee. The HMO pays the primary healthcare provider (HCP) directly for services rendered, according to capitation, fee-for-service, per diem or case payment system. Under the capitation system, providers are paid a monthly fee in advance, of approximately $5 per month, per beneficiary. Secondary and tertiary HCPs are paid on a fee-for-service basis. Only those pharmaceuticals on the NHIS formulary is developed based on the national essential drugs list, and generics are strongly favored for inclusion on the list where available. Although this policy was enacted in 1999, its implementation did not start until 2005.  


My Position
I agree with the overall objective of this policy which is to ensure universal access to good healthcare services, limit the rise in healthcare costs, facilitate equitable distribution of healthcare costs among different income groups, and to reduce the financial burden of paying substantial medical bills out of pocket. A policy like this is important for a country high levels of poverty and unemployment. The 2010 Nigerian Poverty Profile Report  stated that 61% of Nigerians live below the poverty line, a 5% increase from 1999 when the health insurance policy was enacted. The policy covers primary care and treatment of endemic diseases which will help to reduce disease burden. 


However, the policy as presently enacted will do little to significantly improve the health indices of Nigeria. It does not provide timeline for starting the implementation of insurance programs for the informal sector. So far, only the Formal Sector SHIP is being implemented and there is no insurance for the unemployed, retirees, children, and the entire low income segment of the society. A lacuna in the policy has made states reluctant to join the scheme, so far; only two of the 36 states have enrolled their employees into the scheme. 


More so, more than half of Nigerians are either traditionalists or Muslims and both allow marriage to multiple wives with many children. Therefore, the proviso allowing only 4 dependents on the scheme has excluded many other possible beneficiaries. In a recent interview, a regional coordinator of the scheme disclosed that only 4.5million Nigerians are accessing their healthcare through the scheme. This is only 2.7%% of the total population. 


Conclusion
A universal health insurance for the Nigerian people would be a laudable idea. The NHIS policy presently benefits the employed and influential segement of the population leaving out the poor and vulnerable group. I recommend an urgent review of the policy to fill the gaps and implementation of the other SHIPs. The time to act is now. 


References

1.    National Demographic Health Survey 1999

2.    UNAIDS Facts sheet - http://data.unaids.org/Publications/Fact-Sheets01/nigeria_en.pdf

3.     Federal Office of Statistics (FOS), United Nations Children Fund (UNICEF). Multiple Indicator Cluster Survey 1999.  Lagos, Nigeria: FOS and UNICEF, 2000.

4.    WHO Statistics 2011 - http://www.who.int/whosis/whostat/EN_WHS2011_Full.pdf

5.    NHIS website –  http://www.nhis.gov.ng/

6.    Nigerian Poverty Profile Report 2010

7.    Newspaper Report on NHIS implementation - http://www.vanguardngr.com/2010/10/nigerias-health-system-ranks-197-of-whos-200-nations-nhis/

Nigeria's National Health Bill: A Call for an Immediate Assent

In Year 2000, Nigeria ranked 187^th out of 191 countries in the ranking of health systems by the World Health Organization. Although the Nigerian people needed no ranking to know that the health system was in a marasmic-kwashiokor state, the WHO report served as an awakening call to the political class to take actions expeditiously to reverse the deplorable situation. Reports of various technical committees set up by the Federal Ministry of Health culminated in the submission of a HealthCare Reform policy in the form of National Health Bill to the National Assembly in 2004.

It appeared as if the bill made the federal legislators narcoleptic as it took seven years of advocacy and protests before it was finally passed in May 2011.

A protest that preceded the passage of the National Health Bill in 2011

The provisions of the bill include but not limited to;

• Free medical care for children under 5 years old, pregnant women, the elderly (above 65yrs) and physically challenged people. 
• A minimum of 2 per cent of consolidated fund of the federation for primary health care.
• A guaranteed basic minimum health package for all Nigerians
• Unconditional acceptance and treatment of patients with emergency health conditions by public and private health facilities.
• Absolute confidentiality of medical records
• Ensures good quality of healthcare services through the issuance of Certificates of Standard to all health facilities.

The full document can be downloaded here: http://www.herfon.org/docs/Harmonised-NATIONAL-HEALTH-BILL-2011%20doc.pdf

Within the seven years the bill stayed in the National Assembly, it was estimated that Nigeria lost 7 million children and 3.8 million mothers. A few months before the passage of the bill, President Goodluck Ebele Jonathan reportedly made commitment to the UN Secretary General that he would sign the bill as soon as it was passed. While Nigerians were in ecstasy about the passage of the bill despite the delay, one had expected an immediate presidential assent. Unfortunately, that is yet to come almost one year after.

President Jonathan with UN Secretary-General, Ban Ki Moon. 

While I must acknowledge that there may have been significant improvement in the Nigerian health care system in terms of infrastructure and human capacity development over the last 12 years, same cannot be said of the health of the Nigerian people. Nigeria has consistently maintained an unenviable position in the bottom quarter in all global development and health indices. Some of these include;

•         156^th out of 187 countries in UNDP ranking of global Human Development Index 2011
•          41^st out of 53 African countries in 2011 Governance Rankings by Mo Ibrahim Foundation
•          104^th out of 110 countries in Prosperity Index by Legatum Institute, a London based public policy organization (our health system ranked 106^th).

According to the National Bureau of Statistics (NBS), almost three-quarter of Nigerians (72%) lived below poverty line in 2011, an increase from the previous years even as the global poverty level has remained on the decline. Following the subsidy removal policy that led to a 50% increase in pump price of premium motor spirit (PMS) without a concomitant rise in income, more Nigerians are bound to fall below the national poverty line. The lingering insecurity problem in some parts of the country has also grounded the economy of the affected states and brought untold hardship to the people. Experts have predicted that Nigeria may have more poor people than China by 2015 if the current trend continues. Victims of the Boko Haram terrorism are either losing breadwinners/ life investments and/or getting permanent disabilities. This suggests that much more Nigerians would not be able to afford quality health care thereby worsening the morbidity and mortality from prevalent preventable and curable diseases.

Below are our tragic and deteriorating health indices:

• 1 million children die every year => 2740 per day or 114 per hour; the highest in the world
• 52,900 women die from pregnancy related causes every year => 145/day or 44 per hour; the 2nd highest in the world. In other words, 1 in every 13 Nigerian women die from pregnancy and child birth.
• 292,000 neonates (babies below 28 days old) die every year => 800 per day or 33 per hour - the 2nd highest in the world. 
• Average Life Expectancy of 50years, among the lowest in the world.

Although some professional bodies reportedly complained about some provisions of the bill; this is not unexpected in a democracy and as such cannot reasonably explain the delayed assent. No responsible government would be leading a country with the above health indices and delay action in reversing the situation. I humbly call on our dear President Jonathan to kindly sign the National Health Bill without further delay. I also implore all well meaning Nigerians and lovers of the Nigerian people to join this call for presidential assent to the bill. 

God bless you! God bless Nigeria!!

References

•      WHO Health Ranking 2000 - http://thepatientfactor.com/canadian-health-care-information/world-health-organizations-ranking-of-the-worlds-health-systems/
•          Legatum Institute Prosperity Indx - http://www.prosperity.com/country.aspx?id=NG
•          UNDP Human Development Index - http://hdr.undp.org/en/media/HDR_2011_EN_Tables.pdf
•      WHO World Health Statistics -  http://www.who.int/whosis/whostat/EN_WHS2011_Full.pdf