31 Jan 2008 |
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National Health Insurance Scheme: Popular Name Or A Model For Realistic Change In Healthcare Delivery In Nigeria The applause given to the National Health Insurance Scheme (NHIS) initiative across political, media and labour organisation cannot be overestimated, and rightly so for the potential it has in creating easier access to healthcare services by the wider population and across all locations. The most highly envisaged significance is the removal of the heavy burden of paying upfront for such services, which has been the greatest barrier for the poor and most vulnerable people in the country. It is also important to point to the business concept in the initiative on the aspect of introducing competition between the public run and privately managed healthcare provider organisations, as well as between the private institutions and international providers. There is no doubt that it will become a driver for quality, research, efficient strategic management, better training and employee salary and remuneration with associated job satisfaction. With these being achieved, the need to seek career opportunities outside the country would decrease thereby arresting the brain drain among the highly skilled clinical and non-clinical healthcare professionals/experts, which continues to benefit the developed nations at the detriment of Nigeria and other developing countries. Adam Oshiomhole asserted that the idea was first mooted in 1962, (Okumephuna and Chukwuwike 2005) (online access from onlineNigeria.com). Some of the children born since that date are among the leaders of today and yet, healthcare remain one of the most elusive essential public services for the people of Nigerian, especially the poor, weak and vulnerable members of the population. NHIS was later enacted into military law by Decree No 35 under the regime of Alhaji Abdusalami Abubaker on 10th May 1999. The initiative was kept alive by Chief Olusegun Obasanjo the successor of Abubaker as a democratic President. Despite the eloquent speeches and show of commitment by himself, the then Minister of health, Professor Eyitayo Lambo failed to bring the idea into practical reality throughout the period of his ministerial stewardship. There is evidence of another wasted 7 years before Nigerian National Health Conference (NHC2006) was held on 28 – 29 November 2006, barely six months before leaving office, to again discuss the nation’s healthcare strategy for which a beautiful communiqué was produced for a population that thank leaders for doing very little in their public duties, and gives a usual hands of applause for ‘all talks and no action’ syndrome that the people have grown accustomed to. In that communiqué and the televised speech of the Minister, it was obvious to deduce some of the sources of the information used even though the sources were not acknowledged. One of such sources was from the Strategic Concept for Managing Healthcare in Nigeria, which was sent to the Federal Government and Minister for Health via the Nigeria High Commission in London. NHIS has so far been treated as a myth of ‘be all and end all’ strategy, which has undoubtedly occluded the vision for strategic concepts that should be the foundation for a seamless health system which NHIS should shield in respect of funding and monitoring. The strategy is yet to be adequately substantiated in practical terms to account for the population of the unemployed, elderly and disabled people; pregnant women and all children who are under 16 years of age. The NHIS concept is ambitious but achievable, except that the implementation could be marred by the usual bureaucratic bottleneck. One key issue with NHIS is that it is associated with American model of healthcare funding, which has a history of erecting health inequalities in America, and currently becoming a political battle ground for change. This issue has been argued by me; see ‘Financing Healthcare in Nigeria’ in the book, ‘Strategic Concept for Managing Healthcare in Nigeria’. The challenge in effectively implementing NHIS in Nigeria, unlike the USA lies on the following parameters. First, there is a huge variation in the socio-economic empowerment and orientation for insurance security. Second, the potency of the law in USA streamlines professionals to their specific lines of specialism. Third, there is variation in the individual, state and federal commitment to research and research income/funding. Fourth, there is little or no trust by Nigerians for the leadership and big corporations like insurance companies. The word ‘insurance’ is alien to many and an ideology that would require much effort to market. In an evolving economy like Nigeria, the USA funding model would not serve the interest of Nigeria and the only tax funding system of the UK would not be a better alternative. There would be a need to consider a mix-system that is developed to accommodate the recurring, predictable and unpredictable health challenges across every community, the populations’ social orientation in view of attitudes, values and cultural/religious beliefs, literacy and natural knowledge, employment level and the earning and spending capacity of each family. In order to meet the objectives outlined by NHIS, and to serve as a framework for realistic change, strategic stakeholders group should be mobilised to establish and define the respective institutions for promoting good health and preventing disease occurrence, delivering health services in emergency situations, ambulance services, investigations, diagnosis and treatment, chronic disease management, research, procurement, information technology services, laboratory services, pharmacy and drug related management, African traditional medicine delivery and research, training and continuing professional development of all healthcare workers. The above is not an exhaustive component of a healthcare system, which must be efficiently and effectively coordinated to enable a well flourishing synergy for data collection and recording, and smooth referral processes between institutions, departments and specialties. Parallel to the above is the establishment of clear criteria for monitoring and sustaining quality output and workforce performance, unambiguous complaint management procedure/processes and comprehensible policy for punishment in the event of incorrigible poor performance. In addition, there must be a sound national standard for dealing with issues of professional negligence and claims for compensation. It is highly recommended that team of health management strategists, clinical experts and media; representing the wider public should be incorporated into the team of the strategic stakeholders group. The importance of the media in publicising the NHIS initiative, as well as in developing it through publication of independent experts’ comments and criticisms cannot be underestimated. NHIS is a national political discuss that should attract greater interest of critical analysts and less of ignorant praise-singers in order to identify its strengths and weaknesses as well as its threats and opportunities. The most challenging aspect in the discuss is the ability of the leaders to see constructive criticism as a tool for learning and development, and so take stride in engaging the experts against putting square pegs in round holes. NHIS is a popular name, but very few people could comprehend what it is all about and how it aims to achieve what it is intended to do. In an informal and unstructured interview of 200 healthcare workers in Delta State between March and April 2007, more than 90% said they have heard of NHIS, but less than 15% could make any comprehensible description of how it could benefit the public or impact on their work. 70% don’t have faith in it and strongly believe that the leaders and champions of the initiative wants to use it like other white elephant projects to enrich themselves. Another 70% supported their believes on the basis that those with responsibility to implement the NHIS agenda actually receive healthcare services from abroad and the most highly equipped healthcare institutions in the country, particularly those run by oil companies. The survey may not be relied upon as empirical qualitative research for obvious reasons, but the significance of the outcome cannot be ignored. It highlights the fact about the effectiveness of NHIS and the lack of ownership even by those that will implement it at the operational level. This explains the bigger challenge for getting the wider public, most of whom are illiterate and unemployed to take ownership of the scheme and support its viability. NHIS would be less successful if it remains on a solitary course of healthcare management strategy because Nigeria needs to establish a functional and sustainable systems strategy as a foundation for delivering the objectives of NHIS. I have the belief that NHIS is the framework for sustainable funding that will support a model for implementing realistic change in the nation’s healthcare reform if pragmatic and strategic efforts are supported unequivocally by political will. There is a need for constant debate on Nigeria National Healthcare System and the NHIS initiative for its better implementation among the stakeholders in Nigeria and relevant healthcare management experts in Diaspora. More issues would be identified from comparative analysis between the representative group of Nigerians across the globe with relevant healthcare strategic management knowledge and experience and those with clinical expertise.
Author: David Eboh, BA (Hons), MBA, PGDipHE, MIHM, AfCIPD Chief Executive / Principal Consultant, Mebod Management Ltd Contact Details: 82 Woodbrook Road, London SE2 0PA deboh@mebodmanagement.com, davideboh@aol.com Telephone: ++44 (0) 7956378017
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