Guardian

DESPITE its dream of securing universal coverage and access to adequate and affordable healthcare in order to improve the health status of Nigerians, the National Health Insurance Scheme (NHIS) is yet to enjoy good support from state governments, Acting Executive Secretary of NHIS, Dr. Abdulrahman Sambo, has said.

The Scheme established under Act 35 of 1999 by the Federal Government of Nigeria, is aimed at providing easy access to healthcare for all Nigerians at an affordable cost through various prepayment systems, especially for those participating in the various programmes/products of the Scheme.

Sambo told journalists at the weekend that among the three tiers of government, it is only the Federal Government that is making contributions to the scheme. He said, however, that his office has since embarked on advocacy to states on the need to embrace the scheme, noting that some states had started showing signs of adopting it.

He said: “It is only the Federal Government that is paying its own contribution to NHIS and NHIS has been covering backlog of people. But, what have we been doing to ensure that all Nigerians are covered? We won’t just fold our hands and say ‘no, we have problem with our law; we can’t implement’. No! So, we have been going round all the states sensitizing the governors, sensitizing the political leaders, the traditional leaders and individuals to appreciate the value of health insurance and the need to adopt one form of NHIS programme or another.

“Realising the complexity of Nigeria and absence of social security system, we now design programmes that will fit into the different socio-economic groups that we have identified because it is about financing health.  We have to categorize the people into socio-economic groups. That is how we now designed community-based health insurance programme where individuals living in a defined area or having one form of association such as motorcycle riders association, drivers’ association, farmers and others. They can come together and make their contributions into a pool managed by them or in they may want NHIS to do it on their behalf. NHIS assists in the management of that scheme.”

He said that many people were yet to understand the NHIS scheme in full, as such, the misgivings.

His words: “Most of the challenges we are facing are borne out of the fact that most people don’t understand what NHIS stand for. I will start with health care in general. Like any service provision, especially social service, there is the supply side and there is the demand side. Health is a product. You have the hospital; you have the infrastructures in hospital, and you have the human resource components in the hospital. Then, on the demand side, you have patients that are going to the hospitals to access care and services of the hospital.

“Now, in the process of doing that, costs are incurred. The question is: who settles the costs? Who provides the hospitals? Who constructs the hospitals? Who provides the equipment in the hospitals? There is cost to the supply side; there is cost to the demand side. Now, NHIS is about addressing the cost of the demand rather than the supply side. NHIS is not about building hospitals, it is not about buying equipment for the hospitals. It is not about training staff or recruiting staffs to offer services in the hospitals. NHIS is about making it easy and affordable for patients to access health.”

He went on: “How do you pay for health care? This comes in one to three ways. You can say you are on your own or government say ‘I will provide for you free health care’ or a combination of the two. And, lastly, it comes through insurance. These are the ways health care is financed globally. When it comes to cost for the demand, there are two broad categories: direct taxation, which means that government will tax people to collect money and fund the hospitals directly. This is the model United Kingdom has adopted.  There is no insurance per say, people are taxed. When we collect the money, we ensure that hospitals are well stocked with drugs, equipment and all that. If you go to the hospitals, you don’t have to pay a dime.

“The other one is the insurance model which Germany and other countries of the world adopted. Under this model, there are two broad insurance in health, which are social and private health insurance. Social health insurance is where the government comes in as part of its social responsibilities to the citizens to ensure that health care is assessed and made more affordable to the people and payment is made based on ability to pay. It takes the form of individuals coming in, and government organizing individuals either through their employers or those who are unemployed, who are so poor that they cannot afford anything.”

He said that the constitution had made it so loose for health to be responsibilities of the three tiers of government.

“The federal government is paying its own contribution on behalf of federal employees but the state employees and local government employees are not covered because state government is an employer; local government is an employer,” he added.

On why the states were not buying in to the NHIS, he went on: “Some states see NHIS as a federal government agency that cannot come and dictate to them how they provide health to their staff or people. You all know that we don’t have any social security system in Nigeria. Social security is beyond health. If you are poor, you can’t send your child to school. Who should take care of that? It is such a responsibility. Without that, we can’t have social security system in place. When NHIS was set up, the law that set it up was made during the military era when there was a unitary form of government so to say. Though, there were states and local government, there were military administrators where the Head of States could direct states and local governments to do so and so and they would comply.

“Immediately after the Act was signed, Obasanjo was sworn in; it was signed in May 1999, the same month that Obasanjo took over. The law from that day became un-implementable. States became totally independent when it comes to health. Now, the other challenge that NHIS had was that democracy was just coming in then; most political parties then wouldn’t want to be seen to be asking people to pay something. They started preaching free health care. But, you walked into the hospital, they prescribed a drug for you; you know you will have to go and buy. Is that free health care? And, where will NHIS come in?

“If you go to the states, they will tell you they are providing free health. Are they really providing it? The perception of free health is to have the hospitals, to have the doctors and the equipment. Then you go there to access services. But, now you pay for laboratory services, you go for bed space; do that and that and that. I am sure we all at one point or another had somebody who was sick and visited the hospital. You will see the bill individual is given. And, we see on a daily basis requests for assistance on various issues and yet states will say they are giving free health care, free education.”

He spoke of how Ghana came to Nigeria to study the NHIS system and adopted a similar system.

According to him, “today everybody is covered in Ghana. But Nigeria’s NHIS is still at the federal level. Ghana did what Nigeria refused to do, set aside the percentage of Value Added Tax (VAT) and passed to the NHIS. 20 percent of VAT goes to the health insurance agency and provides care for all Ghanaians.

“We wanted to do that through the Health Bill which is yet to be assented to. A percentage of the consolidated revenue, at least one percent should come to NHIS. How much is that? It is about N50billion. Would that be adequate to give cover to all Nigerians? No. N50billlion per annum to provide cover to 160million people; how much is that per person? May be, N1000 per annual; certainly, it will not be adequate. Yet, it is something. If the Bill has been passed, we would have used it to provide cover to some of the vulnerable groups that we mentioned.”

He said that about 2.7 million people were currently covered under the scheme in Nigeria, stressing that the NHIS amendment bill before the National Assembly would make it compulsory for the private sector to enroll into the scheme.