Nigeria's Problematic Health Insurance Scheme
By Reuben Abati
One of the major fall-outs of President Umaru Yar'Adua's prolonged absence from the country and his seeming "incarceration" in a Saudi Hospital has been the protest that if the Nigerian health care system were developed and well managed, the President not to talk of ordinary citizens would not have cause to travel abroad for medical treatment. Meaning: if President Yar'Adua had been in a Nigerian hospital receiving treatment, the noise about his health would have been less strident. But unfortunately, Nigeria runs a healthcare system that is worse than what they have in Haiti where tragedy has currently assumed its original human form. The seriousness of this matter was conveyed afresh only a few days ago, I guess inadvertently, through an advertorial in The Guardian newspaper placed by the management of the NHIS (Thursday, January 14 at page 62). In it, the NHIS says it is suspending a number of HMOs and HCPs. The import of that advert is that the National Health Insurance Scheme is not working. It has failed. This is the simple fact.
When the NHIS was introduced by the Obasanjo government, the expectation was that it would help to improve access to healthcare for the majority of Nigerians, particularly persons in the public service and the private sector. In typical Nigerian style, the scheme began to die slowly a-burning. Many Nigerians depend on out of pocket spending for healthcare. With widespread poverty in the land, this creates special difficulties; unable to spare an extra Naira on healthcare, many Nigerians patronise quacks, or they make compromises with their health with tragic consequences. Even the educated, acting out of ignorance or expediency make uninformed choices. The NHIS as conceived was meant to bridge an existing gap and widen opportunities for access to qualitative healthcare with strong private sector participation, and with government defining policy and framework.
Nobody had any illusions that a national health insurance scheme would solve all of Nigeria 's problems, surely a strong primary healthcare system would still be required to care for the usually marginalised segments of the population. But through insurance a sizeable and strategic segment of the population would have been captured. In the United States , health care reform remains a major issue, but despite the controversies, the national health insurance scheme works. The British NHIS is also so attractive that many Nigerians travel regularly to take advantage of it, even when they are not resident in the United Kingdom . I hope I am not revealing any secret among the immigrant community but I understand there is a way around these things to enable even ordinary visitors masquerading as residents to have good medical attention in the UK . Britain has been running a health insurance system since 1911; Germany since 1883.
As ever, the Nigerian system needed to be strengthened. In 2005, when the NHIS was officially launched, the then President Olusegun Obasanjo had uttered the following words: "with the start of the National Health Insurance Scheme, (NHIS), we see a future of opportunity to improve our health indicator which is related to our poverty index. The scheme will never go the way of other government programmes. The scheme will prove to Nigerians, our administration is serious and sincere about the reform agendas." Four years later, nothing has been proved. The poverty index has risen, and so have the country's poor health indicators. Initially, Nigeria 's NHIS had faced problems arising from what was defined as "global capitation"; in layman's terms that came across as rivalry among several professionals and service providers within the health sector but it was all the more about how to share revenue.
Nevertheless, this was the least of the problems. Managing a health care system for results and actual difference requires leadership, careful management, and capacity building. As at 2005, average expenditure on healthcare as measured through GDP was 4.6; Federal Government average expenditure on health was about 1.5 %. Very poor you would say, but state and local governments fared worse. And yet ensuring the well-being of all Nigerians is part of government's constitutional mandate. Not doing so is a violation of the rule of law. Nigerian governments have voted for the latter, indeed the failure of the NHIS is a comment on the failure of governance.
In the advertorial under review, the management of the NHIS claims inter alia,, that HMOs have not lived up to expectations, they have not made "sufficient progress" and that further re-accreditation of HMOs will be necessary. It is not impossible that certain HMOs have not been so efficient. The irony though is that HMOs have long been in the business of health insurance in the private sector before the same policy was formally adopted. What happened to the pool of knowledge that had been acquired? The NHIS advertorial does not tell the full story, but it also does in a way through the caveat that it provides rather conclusively. According to the NHIS, "the suspension shall not affect the following categories of providers: i. Providers in states folding into the Community Health Insurance Programmes for the Maternal and Child Health Project. ii. Providers in states folding into the NHIS Formal Sector Programme where additional facilities would be required." Our straight interpretation is that the big problem with Nigeria 's NHIS is the ambition of the Federal Body to seize control of it. This does not serve the purpose of efficiency rather it satisfies the urge of a cabal for power and profit. The NHIS in its concluding paragraphs uses the phrase "fold into", that is, the states folding into the NHIS formal sector programme. We are confronted here, therefore, with the original problem with Nigerian federalism. We run an over-centralised state. The centre would rather dictate what happens in other parts of Nigeria in scandalous breach of the law!
The management of the NHIS needs to be told a few truths. One, health is on the concurrent list. The states don't have to fold into the Federal NHIS programme. They can set up their own management and administrative systems and accredit their own HMOs. Two, at the root of the Federal NHIS office's territorial aggression is money. NHIS wants subscription from the states. At least two states have hurriedly co-operated (Bauchi and Cross River states, but even that is not working). The states can have their own separate NHIS programmes which will not run contrary to the national NHIS. This allows for variety and diversity rather than over-centralisation. HMOs can then operate independently at various levels, they do not have to be under the control of a Federal Government that is widely regarded to be absent-minded.
Three, our fear is that when civil servants seek to over-centralise everything as the NHIS authorities are struggling to do, they are not interested in the public good, they are more interested in creating a large pot from which they hope to draw honey until the pot is bankrupted. There have been integrity questions in the past about the management of the NHIS. Even now, there are questions about premiums paid. The NHIS insists that premiums are non-refundable. But when they are non-refundable, where do they go? To what purpose are they put? Four, our biggest concern is that the NHIS authorities in Abuja , talking about regulation and accreditation, are only interested in the collection of premiums. They seem to have abandoned regulation the object of which should be to make sure that the stakeholders do their job, a point that is only faintly, albeit cleverly referred to in the advertorial under review.
On December 4, 2009, ThisDay newspaper at page 50 published an interview with the Director-General of the NHIS, Dr Dogo Muhammad titled "Why NHIS may not achieve universal coverage." The DG provides a self-indicting explanation that he should be ashamed of. He says in simple terms that the only reason the NHIS is not growing is because some states have refused to place their health schemes under the umbrella of the Federal Government. Why should they do so in a federal system, and in a matter that is concurrent? Dogo Muhammad wants the enabling law changed. What he really wants is more powers for the Federal NHIS. He is wrong. Universal coverage will be better achieved through decentralisation and greater investment in primary health care targeted at the poor. I admit that there are countries in the world where healthcare insurance is completely public sector driven as part of an overall reform framework, but it is a model that is ill-suited to Nigeria , given government's record of performance.
What Nigerians need is a healthcare system that guarantees access to qualitative medicare at affordable price. There is no denying the fact that Nigeria 's healthcare index is very poor, and that the people are suffering. Today, this country has one of the highest maternal morbidity and infant mortality rates in the world. Public hospitals are grossly under-equipped. Private hospitals provide cash and carry services, and take-away medical services too, a sign of the intrusion into the medical sector of the fast food phenomenon. Self-medication is on the increase just as the market for quackery has blossomed. Governments at all levels provide little support for the medical sector. There is a yawning gap between promises and actual performance. When Nigeria 's big men fall ill, they jump onto the next available aircraft to seek help abroad.
Without any doubt, the NHIS over which so much air has been split is a programme for the elites. Providing a non-discriminatory, broad-based healthcare opportunity for all Nigerians should be the overriding objective. There is a lot to be done. Health workers need to be motivated to take their jobs more seriously and to be interested in serving Nigeria, not a foreign land whose attraction are the better conditions that it promises. Governments at all levels must assign more funds to the growth of the health sector with international standards in mind. Special attention must be paid to colleges of medicine, teaching hospitals and health related institutions to ensure quality training of medical personnel. A lot more energy should also be devoted to public enlightenment and the creation of social safety nets. People need to know what health insurance is all about: are they entitled to discounts? Is there a linkage between lifestyle choices and health insurance packages? Can they make choices and if so, what kind of choices?
In March 2007, the following memorable statement was made by President Umaru Yar'Adua: "My personal experience demonstrated clearly the inadequacies of the Nigerian healthcare system. When I become the President of the Federation, I will fight to ensure that no Nigerian travels beyond the shores of the country to seek or obtain medical care" (ThisDay, March 20, 2007, p. 19). When the same man became President two months later, he forgot to include health in his famous seven-point agenda. He has since then travelled in and out of the country for foreign medical care! For the past 50 days, he has been in Saudi Arabia in a hospital. I doubt if the President is on the NHIS. So, who is picking up the bills for his long stay in a Saudi Arabian hospital? The same funds should be more than enough to set up a world-class hospital to take care of his health problem.
Nigeria is losing all that. In real terms, the entire nation is sick. When the opportunity arises, someone should calculate and announce how much it is costing Nigeria to keep the President in a five-star hospital in Jeddah , Saudi Arabia for such a prolonged period. The short of it on all fronts is good governance which Nigeria lacks. I recommend a review of the NHIS and a decentralisation of the health insurance system in law and operation. The role of government should be restricted to regulation and monitoring and no more. Finally, a point of information: much better progress is being made with the NHIS in Ghana next door.