By Wole Oyebade, The Guardian
PIQUED by the low coverage of the National Health Insurance Scheme (NHIS) in its seven years of operations, Health Maintenance Organisations (HMOs) in the country have sought the support of Microfinance Institutions to have more Nigerians covered through the Pro-Poor Private Health Insurance (PPPHI).
The goals of the collaboration in the PPPHI, which is now in its pilot phase, are to safeguard the health of poor Nigerians who are customers of the Microfinance Banks (MFBs) through health products offered by the HMOs.
Speaking at a meeting of the HMOs and MFBs, organised by Partnership for Transforming Health Systems Phase II (PATHS2) in Lagos at the weekend, Health Financing Officer PATHS2 Lagos, Dr. Ayodeji Ajiboye, said that the PPPHI initiative was one of PATHS2’s way of contributing to service delivery by way of making affordable and available, health insurance product to the poor.
Ajiboye said that the move was a way of mobilising private resources, through the HMOs and MFBs to provide health insurance to the clients of the MFBs and help them get prompt affordable treatment.
He noted that the MFBs already have the platform to service the poor, while the HMOs have the expertise of providing health insurance, saying the initiative is therefore leveraging on these to provide additional service to the MFBs clients that are also in need of healthcare.
Ajiboye told The Guardian that PATHS2 had supported HMOs to determine premium prices actuarially, taking into consideration the utilisation trend and the cost of medical care.
“We encourage healthy competition among the HMOs, even as we are very careful about under-pricing to make the insurance plan sustainable,” he said.
Head of Business Development, Healthcare International, Mr. Ayobami Ogungbemi, who noted that that his HMO is targeting no fewer than 10, 000 people in the pilot phase, said that the small premium is sustainable as people that are in SME businesses.
“They get loans for their businesses and while they are paying the loan, they already have the insurance cover. At the expiration of the repayment period, the health insurance continues because it is for a year. They will not have to deep hands into business funds to pay for healthcare,” he said.
Representatives of the MFBs lauded the initiative as one that is in line with the mission of MFIs to improve the standard of living of each client, in this case, the poor Nigerians.
They, however, raised concern on affordable pricing; methodology: either to make it mandatory or voluntary; flexibility of the product and existing challenges of indebtedness by some clients.
Representative of Lift Above Poverty Organisation (LAPO) MFB limited, Kenneth Ndubuisi Okafor added that marketing and educating the poor on the importance of insurance is also a challenge.
“This is because in this part of the world, many still don’t have faith in insurance, including the elites. But we are not dwelling too much on the challenges and risk aspect. We will commence and tackle the challenge as they come. There are obviously more benefits than the disadvantages,” Okafor said.
By Faridah Kulabako, Daily Monitor
Insurers are eagerly eying the planned National Health Insurance Scheme, which is expected to take effect next year, as an opportunity to grow insurance uptake in the country.
The NHIS is a compulsory form of health insurance care financing where people who earn a monthly income will be obliged to pay a pre-determined premium to the scheme. It will enable members including their families to access quality health care services from an approved public or private health facility.
The Insurance Regulatory Authority director operations, Mr George Okotha, said the introduction of new products such as health insurance and micro insurance will help boost penetration and premium volumes. “The more products we have, the better for the industry. We are now going into products that have a direct impact on people’s lives,” Mr Okotha said.
At 0.7 per cent, Uganda has the lowest insurance penetration in the region, compared to Kenya’s 2.6 per cent, and Tanzania and Rwanda’s 1 per cent respectively.
However, currently, not many insurers offer health insurance packages due to the complexity of the product, requiring specific investments in that line of business.
Not many Ugandans take up medical insurance products apart from a few schemes that are mainly funded by employers on behalf of their employees, leaving the biggest part of the population, especially the unemployed and low income earners who can’t afford the highly priced medical packages.
By Oyeyemi Gbenga-Mustapha, The Nation
Dr Mohammed Dogo, Executive Secretary/Chief Executive Officer, National Health Insurance Scheme (NHIS), in this interview with Oyeyemi Gbenga-Mustapha presents a scorecard of the organisation’s activities in the past 12 months vis-à-vis challenges and prospects for the New Year.
SOME enrolees are alleging that their premium does not cover certain diseases, especially terminal ones, why is this?
Whenever you develop a social health insurance, it does not cover everything. Social health insurance looks at the burden of diseases in a society or country and tries to capture 80 per cent to 90 per cent of the disease burden. That is the case. So by the time you try to think cancer, it means all is susceptible to getting cancer. The basis is that if Nigerians want to get cover for everything, they should be ready to pay more. The scheme is contributory. It is not free. As of today, no employee of the Federal Government has started contributing six years after the scheme took off, yet they want increase in the benefit package. Better soup, na money kill am. If you want everything, more money has to be paid. The Federal Government is standing as cover for its employees and is paying 10 per cent on behalf of its employees and that is the agreement. Labour on behalf of employees say too many deductions were being carried out in their earnings, so labour in the light of the need to expand benefit to cover more services and diseases, said we should carry them along to see where more resources can be mobilised. Let me add that the scheme takes care of preliminary of diseases. If for instance, a lady notices a lump in her breast, she will have biopsy and if it is not advanced, she will have radical mastectomy. It depends on the level of cancer we are talking of here. If it is confirmed as malignant cancer, she cannot get chemotherapy or certain treatment, which is exclusive. If somebody has prostate and cancer is detected, radical mastectomy would be given, early cancer can be covered under the scheme, but late cancer, where a person requires real treatment, at the moment, the scheme cannot bear the cost. It is not about what we want, but about what can be given to Nigerians in lieu of the available resources.
The theme of the gathering in Kano was ‘All stakeholders’ summit for the amendment of the National Health Insurance Scheme (NHIS). But only members of the House Committee on Health were prominent, why?
That was supposed to be a re-treat with the Senate Committee on Health. And this aspect is just to know and gather what the people have got to say about the Act. This Act has got a lot of grounds since 2005. It has enjoyed the presence and input of all the stakeholders, but this is the last lap and we’ve gotten the bye-election of the legislators’ now we want to do something with it and use this opportunity to call and bring it back to public domain so that there could be new things.
From the contributions, I have not seen anything new. According to the scores by people, essentially all those we’ve been scoring remain germane and that actually are the areas we want to pump up. And because life is dynamic, you cannot say life is static, you will reach a certain stage and say you can have done with it.
I know this Act went to Ministry of Health and Ministry of Justice. It came back. It was to go to Federal Executive Council (FEC), but there was a new National Health Insurance Scheme (NHIS) Board which called it back saying they want to see it. And that is why it took this long. Am glad that with what they seen and the lecture from the legal luminary- whereby he really dissected and exposed those areas that are controversial, that input is more than enough for a new input by any other body.
Are other stakeholders really carried along, because one thing is to send a Bill to National Assembly, it is another to package it by carrying all other stakeholders along?
That is it! In the last six years, we would have had so many summits and fora and we’ve always carried them along, so as far as am concerned, bringing it to this level is not the end of it because once they take it, they are going to debate it and bring it to public hearing again; so there will be more and more opportunities. But we must give them something on where to start. We do expect there will be some input that will affect what we have now, either a deletion or addition. We know National Health Insurance Scheme (NHIS) is a process, and it is not possible in a country like Nigeria to get everybody at the same time because people have their own trades, you can only invite somebody but you cannot force him to come. You can take a horse to the river, but you cannot force it to drink. So really, that is the situation at the moment with the National Health Insurance Scheme (NHIS). What we are interested in is for this Act to cover every Nigerian as much as possible and recognise the Nigerian that cannot contribute and for the government to take responsibility. If we can get that, then the covering is going to be wider.
As you journey towards this Act, what is happening in National Health Insurance Scheme (NHIS) in terms of programmes?
National Health Insurance Scheme (NHIS) started with only one programme- that is the formal sector programme which is to cover the workers in government and organised private sector. In that light, knowing that not all Nigerians are employed, we’ve developed so many programmes over the years, such as Community Health Insurance which was flagged off by the President in December, together with voluntary contributors. That addresses individual that is self employed and interested and that will be contribute. That is also part of community insurance. We’ve developed that programme and tested it and it is working. Now, we are going to cite some sites- about 50 up and down the country. Before we agreed on the number 50, we did an initial inventory-Micro Finance groups in Nigeria; Corporate Societies; all artisans etc. We had close to 70 consultants and they went into nooks and crannies of Nigeria and that is as a result of our activities based on that, we developed some parameters to select those that are likely to quality, because they must score according to our rated parameters which is 70 per cent and above. We’ve selected 50 per geo-political zones and now we are going on verification, to interact through advocacy, identify for instance- do they have a hospital they can access, because you cannot have a community where they cannot access care. This is work in progress. Before the launch, we were engaging different communities for the community health insurance. We’ve developed a programme for students in tertiary institutions-Universities, Polytechnics and monotechnics, etc.
The Health Maintenance Organisations (HMOs) are already piloting that now and we will launch that early this year. You know, some of our students who are above 18 years and are not gainfully employed are covered. Likewise, retires, the PENCOM Act did not accommodate health component. When people retired, they get older and get some diseases like diabetes, more hypertension and other diseases that naturally come with advancement in age. There is now a retiree programme which we’ve been working on in the last two years.
In the last four years, we have had national summits, now we are on zonal summits to get final input from all the groups- how to finance it, what benefit package they are supposed to enjoy and what diseases are to be covered. Because they must get some subsidies, where would the resources come from?! That is another one. The Armed Forces are under 100 per cent cover throughout life, even if they are retired, they will continue to get cover. The Ministry of Defence have written and about to get the approval of the Federal Executive Council (FEC), they got that from our input we have another programme which we would like to be recognised in this Act, that is, the vulnerable. It is for Nigerians who are physically challenged like prison inmates, indigents and orphans who cannot afford care. The programme is tagged ‘Safety Net’. There must be a pool of fund called ‘Safety Net’ that can give them cover 100 per cent. There are many areas from which you can mobilise these resources. Already, we’ve thought of National Health Bill which impacts some amount of money that can be used. That is innovative. In addition, in the operations of NHIS, it is not all a bed of roses.
Can you expatiate on these?
We’ve reviewed the blue-print of all packages; we are awaiting the final report and asking the government to take a look and approve it. We’ve all the benefit packages from primary, secondary and tertiary levels of care. About 38 specialists were selected and they sat for two weeks. They were trying to do the job. We extended for six weeks and we’ve about three benefits packages all comprehensive. Nigerians have been complaining that there are no provisions for cancer, renal failure transplant among others. Now there is everything there. There are now two forms-optimal and basic. We have given those to relevant bodies to complete and see how much it will cost and how much people or beneficiaries can afford. It is giving much people options of choice. And we will make them to know what each package entails. In the Kano workshop, somebody said, what was NHIS doing about drugs lists. All these are being reviewed. In state hospitals, before it was 15 days cumulating, but now 21 days. When people speak like this, we know they don’t know, it is just an argument.
Concerning Health Maintenance Organisations (HMOs) right now, some are delisting individual enrolees, asking them to either withdraw voluntarily or they get delisted because they intend to take on corporate clients. As a regulator, is this permitted?
As regulator, we must first find answers to some questions. Are the enrolees in organised private sectors or federal enrolees? We need to get the facts of what is happening with the HMOs with their private companies being de-loaded from HNIS. Sometimes back, providers were saying some HMOs are owing them over one billion naira, and expected NIS to get them their money. I enquired why the HMO were owing so much when we paying them upfront. They told me these were private business. And I told them that when they were recruiting and signing papers, NHIS did not know, and now that it is sour, you want us as regulator to come in. The same applies to what you have just hinted. We have a way people complain to us- an online service that is 24/7; website and people do write us as well. So am not aware of this brief by you. But if the provider is guilty of such, we need to get a formal complaint from the affected enrolees so we can go after that development as a regulator. No one goes after somebody without an official complaint. A candid example is of three months ago, when a provider complained that so, so, so is happening. I encouraged such to formalise it, but said he was just giving me information. I insisted he should write, but he declined and I told him I am not his houseboy he can order about without evidence. So that is an example of market talk, it holds no water. People should take responsibility to device genuine information, not using us as regulator to witch hunt. If I have evidence, I will call the provider and find out the details and know what to do as a regulator.
By Mohammed Dogo-Mohammad
THE evolution of the National Health Insurance Scheme dates back to 1962, when the need for health insurance for Nigerian citizens was first recognised.
This political will was manifested when, on June 6, 2005, the Federal Government flagged off the Formal Sector Social Health Insurance Programme for its employees.
The scheme was thereafter given a presidential mandate to ensure universal coverage of Nigerians by 2015 through Social Health Insurance.
This implied the provision of sufficient financial risk protection to all Nigerians through easy access to adequate healthcare at an affordable price.
Health Insurance is a social security system that guarantees the provision of needed health services to persons upon payment of a token contribution at regular intervals. The National Health Insurance Scheme (NHIS) was established under Act 35 of 1999 by the federal government to improve the health of all Nigerians, and at an affordable cost.
To achieve this mandate, the NHIS designed many programmes to suit the various socio-economic groups in the country. It similarly developed operational guidelines to ensure effective implementation of the various programmes.
The guidelines spelt out payment mechanisms, accreditation procedures and requirement and quality assurance process among others.
Within six years of the official flag off, the NHIS has given cover to 95 per cent of federal government employees.
Also, over 1.6 million pregnant women and children under the age of five were covered under the NHIS/MDG Maternal and Child Health (MCH) Project in twelve states of the federation. While additional twelve states are currently being processed for the same project.
The Tertiary Students Social Health Insurance programme has further resulted in providing financial protection and health cover to more than two hundred and fifty thousand students in tertiary institutions in the country.
The various private health plans for the Organised Private Sector have been providing cover for those in the sector with their respective families. Other programmes at the verge of being rolled out include cover for NYSC members, prison inmates and retirees.
The programme collapsed with the stoppage of the huge subsidy being granted by the Scheme. NHIS then embarked on full analysis of the factors that would facilitate sustainable Community Health Insurance in the country.
This involved study tours to countries that have “gotten it right” and extensive desk research. Series of consultations were also held with various interest groups and community leaders on factors that could facilitate its implementation in the country.
Also an all-inclusive stakeholder summit was held to further fine tune the implementation blueprint, which was finally developed and presented to federal government for approval.
The blue print recognised three modalities for the implementation of Community Based Health Insurance, taking the peculiarities of the country into consideration.
It was built on the experience of the NHIS in implementing the NHIS/MDG maternal and child health project which was recently awarded a certificate of merit as a good practice initiative by the International Social Security Association at its African Regional Forum in Arusha, Tanzania.
The approach adopted by the NHIS in the implementation of the Community Based Social Health Insurance (CBSHI) initiative took cognisance of community ownership, social solidarity inherent in the Nigerian people and cultures and the various socio-economic groupings in the country.
It further recognised the role of the community in actively mobilising, collecting, pooling and allocating resources for health care. Each community is to also adopt a benefit package for its members while the NHIS will give the required technical assistance in costing the package and actuarial determination of contributions.
Noting the peculiarities in the country, NHIS plans to run a pilot CBSHI in each state of the federation for three years. The pilot communities were selected based on critical success factors identified in them during a comprehensive inventory of community groupings and associations in the country.
The scheme subsequently identified Isanlu community in Yagba-East Local Government Area of Kogi State.
The stewardship role and support of government have been identified as crucial to the successful implementation of CBSHI in all countries of the world.
The NHIS, as an agency of government, and with the approval of its immediate past governing council and the minister of Health will subsidise the CBSHI programme in each of the pilot locations through the payment of contributions for all registered pregnant women and children under 5 for the duration of the pilot.
Community-Based Health Insurance, though a necessary tool for universal coverage cannot on its own lead to the attainment of that objective. Most countries supplement it with private health insurance as a strategy to cover all citizens.
The scheme is also working assiduously to address the vulnerable groups in society. These are those who don’t have the financial ability to contribute to any pre-payment plans. The creation of a vulnerable group fund will certainly be the solution to provision of cover to this group.
The fund could be financed either directly by the three tiers of government through the proposed Health Bill.
The NHIS has proposed the possibility of mobile phones airtime utilisation to raise adequate resources for health. This has been tagged “the one kobo per second” initiative. This is certainly in tandem with the federal government resolve to drive human capital development and economic growth.
Dr. Dogo-Mohammad is the Executive Secretary of NHIS email@example.com
By Ruby Leo, Daily Trust
Halima and her husband Abdul are self employed, the former a market woman while her husband is a vulcaniser. With five children to fend for, things are hard and the family is struggling to survive the hardship of the economy.
Halima says things gets worst for them when they have to squeeze funds to pay for health care when the children get ill, or when she and her husband are down.
According to her, the clinic they access health care practically collects all their income and to meet their needs, they have to borrow.
This kind of situation is normal for most average or low income Nigerians who struggle on a daily basis to make ends meet.
With about only 3 million Nigerians registered by the National Health Insurance Scheme (NHIS) from the formal sector out of the 150 million estimated Nigerians, the cost of health care remains relatively high for the average man.
It comes to show that 75% of the population still pay for their health needs from out-of-pocket which means that a large percentage of Nigerians still pay for their health needs when critically ill.
To reduce the burden of health care, the federal government introduced the formal sector social health insurance programme for employees of the Federal Government in 2005.
Yet, the coverage has been among the civil service, students of some tertiary institutions and the military. Suffice to say therefore that the coverage is still a far cry from the ideal.
A health insurance is supposed to pool resources together to readily provide health care for people even before they need it, therefore it requires a wider scope that is well beyond operating within the formal sector.
In 2005, the National Health Insurance Scheme (NHIS) was given the presidential mandate to ensure universal coverage by 2015. To achieve this, the NHIS is developing various programmes to suit the many social-economic groups in the country.
NHIS also developed operational guidelines to ensure effective implementation while spelling out payment mechanisms, accreditation procedures and requirement and quality assurance process among others.
While it could be argued that the informal sector is unorganized, it does not translate to the fact they cannot be organized for specific purpose through associations, guilds and unions.
For example, there are communities of artisans such as vulcanizers, carpenters, bricklayers, drivers etc that can come together to pursue matters that can be beneficial to members.
Indeed, the National Union of Road Transport Workers (NURTW) is one group that has emerged as a formidable and organized group that is championing the interest of its members.
These groups readily provide the platform for organizations that can transmute into focal groups to further their members’ interests.
It is these groups that seem to be providing a platform for the NHIS to reach out to this informal group and achieve universal access.
The Executive Secretary of the National Health Insurance Scheme (NHIS), Mr. Muhammad-Dogo Waziri, said that considering the vast size of the informal sector in the country, the Scheme has developed a blueprint for the implementation of community based social health insurance programme.
He said: “We have come a long way since the blueprint for community health insurance was approved by the Federal Government. We have developed operational manuals because the term ‘community’ means different things under different circumstances.
“A community could be an economic community like cooperative group such as the road transport workers or groups of artisans. These are different groups that come together to promote an economic interest or interests”.
The NHIS boss hinted that survey had been carried out to know all the existing communities in the country.
“We now have a survey of all the cooperative societies in the country, all microfinance groups, and all groups that are union-oriented with some activities. These are economic groups that can serve as entry points by the time we start community health insurance scheme,” he explained.
However, he added that the community health insurance scheme will cohabit with the existing scheme.
He explained that a team from the NHIS was recently in India to observe how India executed its own community health programme.
He added: “Also as part of the preparation, we had to go and compare notes with our Indian counterparts who had been executing community health insurance scheme for some time and have also recorded high success rate.
India has a community health insurance for the poor that is heavily backed by the government. The three tiers of government teamed up to provide health care for the poor living below poverty line and they run into millions because of the high population of India which has hit about 1.2 billion.
These two tiers of government decided to have a sharing formula. The Federal Government pays 75% while the states pay 25%. We went to learn how they were able to capture these people who are not organized, since the informal sector, is an all-comer affair.”
According to him in India, the responsibilities of collating the poor are given to the state government.
He explained, “Of course we know that quite a number of people who are not all that poor will also want to be a part of this kind of initiative which also presents the challenges of detecting who is not eligible.
Therefore, the state governments were given the opportunity to identify, down to the remotest villages, those that qualify to benefit from the package.
They were subsequently registered after they were given identity cards that have their personal identity number. The states now handed over this information to the Federal Government with their own counterpart funding.
The Federal Government then added its own 75% and then outsourced actual registration given the beneficiaries smart cards and number per family.”
With this innovation, India has now expanded access to health care facilities with about 40 million people covered under the programme.
The NHIS Chief said the Scheme has developed its own Information Technology to ensure robustness and user-friendliness.
Waziri hinted that the NHIS is partnering with a micro insurance academy in India in the execution of the programme in Nigeria.
His words, “With all these experiences, the Federal Executive Council has already approved and we hope that in the next few weeks we would be able to get Mr President to flag off our community health insurance in Nigeria,” he stressed.
He highlighted that the NHIS will embark on massive sensitization of stakeholders on specific roles of all the medical teams to forestall misunderstanding of roles.
His words, “We should not forget that the formal sector is for people who have economic muscles to participate not to talk of an informal sector that is largely unorganized in terms of economic empowerment.
We will sensitize both the givers of service and receivers alike on their roles. This community sensitization programme is very important since the community health insurance scheme is a voluntary contributory programme.”
Waziri stressed that there is no discrimination of packages saying, “the packages being prepared for the informal will not be different from those enjoyed by the formal sector or private sector”.
He stated that the packages will not be uniform across the country as it will take a range of issues on board in deciding what will constitute the packages.