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
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.
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/
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