By Blessing Udeobasi
When the Nigeria Health Insurance Scheme was set up by Decree 35, of 1999, it promised to alleviate the healthcare challenges faced by millions of Nigerians. However, nearly two and half decades later, the scheme has been marked with numerous shortcomings leading to a near defeat of its purpose.
The NHIS was created to ensure universal health coverage for Nigerians, starting with federal employees and expanding to formal and informal sectors. In theory, the brilliant initiative covers a range of services, from consultations to surgeries and maternity care by pooling funds together, to provide healthcare without the financial shock associated with sudden illness or accidents.
While some Nigerians expressed sincere gratitude for a scheme of this nature, many believe that there is still much room for improvement so that the scheme can meet the needs of citizens better.
“My experience with NHIS has been fair despite its ups and downs. I’m already aware that nothing is perfect in Nigeria, but I’d say they’re trying to an extent. It feels good to go to the hospital sometimes and not pay a dime,” says Ms Cynthia*, A federal government employee’s dependent residing in Nsukka.
For employees of federal institutions, both private and public, the NHIS automatically deducts a small portion of salaries to fund the scheme, while other segments of the population can voluntarily enroll. However, despite these efforts, the NHIS’s reach and efficiency are limited. In 2018, Nigeria had the third highest out-of-pocket health expenditures in the world, with 76.6% of all health spending in the country paid directly by individuals.
The World Health Organization also estimates that Nigeria has the highest out-of-pocket expenditure on health in West Africa. Our Dream NHIS Exists Only on Paper In a bid to salvage this situation and to achieve universal health coverage, former President Mohammadu Buhari, in May 2022 signed the National Health Insurance Authority Act into law.
According to the Act, each employer wishing to participate in the scheme registers with the NHIS and is assigned a registration number. They select an accredited HMO and the NHIS issues an ID card to the enrollee and their eligible dependents. The Primary Care Provider (PCP) takes care of all the primary health care issues of the enrollee based on the NHIS benefit while the HMO pays the PCP a global capitation per member every month, which has been pre-agreed.
The HMO also reimburses the specialist on the pre-agreed Fee-For-Service tariff as prescribed by the NHIS whenever the claim is presented. As revealed on the NHIS website, enrollees are entitled to benefits such as out-patient care, prescribed drugs, pharmaceutical care and diagnostic tests, maternity care for up to four live births for every insured couple in the Formal Sector Programme, preventive care, including immunization, family planning, antenatal and postnatal care, consultation with a specialist such as physicians, paediatricians, obstetricians, gynaecologists, etc., and hospital care in a standard ward for a stay limited to a cumulative 15 days per year among other benefits.
Current Reality of NHIS EnrolleesWorthy of note is the fact that it is one thing to enact a law, but another thing to ensure strict implementation across the board. This now begs the question: Is the NHIS meeting the healthcare needs of Nigerians as purported in their mission statement and guidelines? What challenges are preventing the effective implementation of the scheme? How are the failures of the NHIS impacting the health and welfare of Nigerians?
According to a 2017 study conducted by the Research Department of the Central Bank of Nigeria, limited coverage, in-extensive prescriptions, conflict of interests between the NHIS and HMOs, low participants’ coverage, issues of mistrust, total government financing limitation as well as low budget allocation compared to need, were the major issues confronting the achievement of quality healthcare delivery from the Scheme.
“One of the major challenges is that some drugs especially very expensive ones are not made available through the NHIS. Oftentimes, the hospital tells us to either pay out of pocket or buy those drugs from the market because the NHIS does not cover them. There may be other similar drugs that the program covers but in most cases, the most effective one is never covered by NHIS,” says Mr Romanus Ikeh*, a staff of the University of Nigeria Nsukka, who has been enrolled since 2016.
It is not just Ikeh who has faced similar experiences with the health insurance scheme. Ms Rita*, a stay-at-home mum resident in Anambra State told this reporter that she recently visited the hospital and the doctor prescribed a medicine worth N12,000 for her. However, when she got to the hospital’s pharmacy, she was told it was not available and that she should buy it from the market.
“Meanwhile, I saw them giving the same medicine to someone else. When I tried to find out the reason for that, I discovered that the patient they gave the medicine to was not enrolled under NHIS.” Ms Rita said. Similarly, Ms Chinenye* a nursing mother, also a resident in Anambra State said she was denied a delivery mat on one of her visits to the hospital. “When I registered for antenatal using my insurance card, one of the things the doctor prescribed for me was a delivery mat, but when I got to the pharmacy, they just gave me some of the prescribed medications and asked me to pay for the delivery mat because it’s part of surgical equipment which my HMO did not cover,” she said.
Discrimination, Nonchalant Attitude Towards EnrolleesEnrollees of the NHIS have expressed concerns over the discrimination and lackadaisical attitude displayed by NHIS staff towards them in offering healthcare services. “Their services are very poor. You go wait tire. I don’t know if they intentionally scatter patients’ folders. At the hospital where I’m currently enrolled, you’ll spend more than one hour before they even locate your file. They are not organized at all. They will just be looking for your folder everywhere, at the doctor’s office, pharmacy, or registration office. Just everywhere,” Ms Chinenye continued. “As an NHIS patient, if the doctor prescribes a high-priced medication for you, you’ll have to go through a whole lot of processes to get it.
First, they will write to your HMO to ascertain your eligibility for that medication and you will wait for hours for your HMO to reply before you’ll be attended to. And probably, by the time your HMO is sending the referral code, the hospital may have closed for the day. There’s this medicine called MMR vaccine, I needed two doses for my son and it was around N16,000 each. They delayed me for several hours in the name of getting a referral code,” Chinenye added.
For Cynthia, It all depends on the hospital one is enrolled in. She told this reporter that most public hospitals are guilty of neglecting or discriminating against NHIS patients while they give better attention and service to non-NHIS patients. However, she added that private hospitals tend to treat patients better. Even when they discriminate, they don’t do it with impunity as in public hospitals. “I noticed that sometimes when you bring your child to the hospital for a presumed ‘minor illness’ like cough or headache, they don’t take you seriously because they think you’re abusing the insurance and that the sickness is not serious enough to warrant a hospital visit. That’s the kind of attitude we usually face as NHIS enrollees”, Cynthia continued.
The experiences of Chinenye, Cynthia, and Romanus corroborate the findings of a recent study which revealed that academic staff find it difficult to utilize the NHIS due to inadequate staffing, poor management, and negative attitude of health workers.
Way Forward The National Health Insurance Scheme was envisioned as a solution to Nigeria’s healthcare challenges, but it is clear that the system is struggling to live up to its promise. The current economic reality of Nigeria, characterized by inflation, depreciating naira, and rising living costs, has significantly impacted the efficiency of the scheme in several ways. This puts pressure on healthcare providers participating in the NHIS. Many hospitals are forced to either increase out-of-pocket charges for patients or reduce the quality and availability of services covered under NHIS to cope with rising operational expenses.
Essential services like medications, diagnostics, and treatments that should be fully covered are often inadequately provided, leading to a gap between the scheme’s promises and its actual service delivery.In May 2024, the Association of Nigeria Private Medical Practitioners (ANPMP) issued an ultimatum threatening to pull out of the national health insurance scheme indefinitely starting from August should the NHIA fail to adjust the Fee-For-Service tariff, which has remained at N750 for the past 12 years.“We have resolved that within the next three months if we don’t get a proper and equitable review of the national health insurance scheme tariff, we are going to boycott that scheme until further notice,” Kay Adesola, the Association’s president told BusinessDay.
For the NHIS to truly fulfill its promise, more funding is necessary to improve health infrastructure. Much of this funding should not only come in the form of budgetary allocations but also an upward review of the tariff paid to hospitals for the services they render to NHIS enrollees.
There is also a need for better monitoring of the scheme’s implementation to ensure that funds meant for healthcare are not diverted elsewhere. Strengthening partnerships with private healthcare providers and leveraging technology to streamline service delivery could also play a key role in improving the scheme.
- N.B: Sources’ names have been changed to protect their identities
