According to an editorial in Population Medicine by Dalhatu & Don (2022), the National Health Insurance Act of 2022 (NHIA) was signed into law on May 19, 2022, replacing the National Health Insurance Scheme Act of 1999, which had failed in terms of level of enrolment among citizens. One of NHIA’s key goals is to ensure healthcare accessibility for all, particularly vulnerable individuals who lack access to basic care, residing in suburban and rural areas.
The fact that for some reason, when you think of your health, you have a mild kind of anxiety owing to the fact that you have to take a chunk of money you had planned for other things, then channel it to save your life corroborates the narrative that more than 70% of Nigerians have now been conditioned to this habit. Depending on the economic status where you live and other indicators of a health system strength, that number could go up to a high 90%. The 2018 Nigeria Demographic and Health Survey alluded to the low enrolment rate as it was revealed that over 97% of Nigerians lack any form of health insurance.
The NHIA 2022 aims to establish health insurance programs in states lacking them and ensure accreditation of additional facilities to enhance public accessibility. State-owned facilities are integral to the development plan, particularly in rural areas where the government predominately owns healthcare structures. When fully optimized and supported by the Insurance Act, these facilities can effectively address patient needs, including disease prevention, health promotion, and maintenance. They will provide essential diagnostic tests, safe and affordable medications, and vaccines, all contributing to the achievement of Universal Health Coverage (UHC).
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Tied to the National Insurance Act, some of the outcomes expected from a successful national campaign is expected to lead to a shift in culture that favours individuals to take a more proactive step towards their health and wellbeing. Another outcome is that it challenges the health system to deliver due to demand for quality healthcare. This article covers the basic facts about health insurance in Nigeria, some hurdles insurers have to overcome, my discussion with researchers on a typical health insurance scheme from the public sector, lessons from systems outside of Nigeria. All of this information could determine how National Health Insurance Act 2022 can be optimised for the health of all Nigeria.
A RECENT STUDY ON THE LAGOS STATE HEALTH INSURANCE SCHEME
During a recent conversation with Olubukola OLUMUYIWA , a public health researcher in Lagos, I got some insights into the current State of the Lagos State health Insurance Scheme. She discussed the findings from her research. The study, conducted in 2023, sought to assess the effectiveness of the scheme by examining factors such as enrolment rates, health-seeking behaviour, and overall impact since 2018. I enlisted the main points from our discussion below.
- The scheme has enrolled about 6% of the total population of the state across.
- It attributed the low enrolment rate to: little or no awareness about the scheme, enrolment cost especially for self-employed/entrepreneurs, as well as already existing insurance plans by other residents.
- Due to the scheme, enrolees report increased hospital visits due to the assurance of free and quality care, which indicates the utilization of the scheme by the enrolees.
- Despite the positive testimonials shared, the study identified several gaps to the performance of LSHIS such as limited access to quality medicines, insufficient coverage of health services, poor internet connectivity and slow responses from LASHMA needed to be fixed to prevent the collapse of the scheme.
- It was also found that among the beneficiaries there is a huge gap in knowledge about expected benefits from the plan subscribed to, so there is the “what I ordered vs what I got” syndrome running through their minds that could lead to dis-enrolment or discontinuation of the scheme by these beneficiaries.
THE CASE OF LAGOS STATE HEALTH INSURANCE SCHEME (LSHIS)
The Lagos State Health Insurance Scheme (LSHIS) was established in May 2018 as part of efforts towards achieving universal health coverage (UHC) in Lagos State, Nigeria’s largest city with over 20 million residents, according to the Lagos State Health Management Agency (2023). The scheme aims to leverage mandatory health insurance to provide affordable, quality, and accessible healthcare for all Lagos residents, especially the poor and vulnerable.
As stated earlier, to bridge the healthcare access gap in Lagos, Former Governor Akinwumi Ambode, signed into law the Lagos State Health Scheme Law in May 2015 which birthed the LSHIS three years later. Specifically, as outlined in the Lagos State Health Scheme Law (2015), the scheme has the mandate to cover basic primary and selected secondary healthcare services for enrolees with funds pooled by an annual contributory amount determined by residency status. Enrolees only pay small registration fees at accredited facilities with the LSHIS covering the balance of treatment costs directly to healthcare providers.
Corroborating the gaps identified in the study cited earlier by Olubukola Olumuyiwa, one report by the Lagos State Health Management Agency (LASHMA) noted delayed issuance of insurance ID cards is one of the factors accounting for low adoption of health insurance in Lagos State. More so, addressing issues of increasing public awareness & mistrust among residents, inadequate number of accredited facilities and improving health service delivery, costs of insurance premiums have been recommended as critical areas for the LSHIS to successfully translate into substantial gains in healthcare access for Lagos residents (Lagos State Health Management Agency survey, 2022).
Beyond resolving these barriers, is the need to embrace changes quickly, and apply lessons from the success stories of similar schemes in countries. Having an expanded global view where public health service providers indeed have the interest of patients at heart is key.
GLOBAL LESSONS
Rwanda’s Community-Based Mutuelles Scheme:
Launched in 1999, the Community-Based Mutuelles Scheme aimed to provide affordable health insurance to all Rwandans, with a particular focus on rural and underserved communities. The success of the Mutuelles Scheme can be attributed to several key factors. First, the scheme embraced a community-based financing model, where individuals contribute premiums based on their ability to pay. This approach ensured that even the poorest Rwandans could access essential healthcare services without facing financial hardship, thereby promoting equity and inclusivity. Also important is that the Mutuelles Scheme fostered a sense of ownership and solidarity among Rwandan communities, with residents actively participating in health education programs and community health initiatives. This grassroots engagement not only helped to raise awareness about the importance of preventive healthcare but also strengthened social cohesion and resilience in the face of health challenges.
Thailand 30 Baht Universal Coverage Scheme:
Sharing a common problem of large proportion of citizens uninsured in Nigeria, the 30 Baht Universal Coverage Scheme by the Thai government aimed to provide healthcare to citizens. At its core was a concept: a flat-rate fee of 30 Baht for all essential healthcare services. This nominal fee, designed to be affordable for even the poorest citizens, served as a gateway to comprehensive healthcare coverage. There were also other enablers. The government tripled the number of primary care units, ensuring that healthcare services were accessible to even the most remote communities. Additionally, a comprehensive public education campaign was launched, utilizing various mediums such as television, radio, and community events to raise awareness about the benefits of health insurance and encourage enrolment.
Philippines Health Insurance Corporations:
In the Philippines, access to healthcare has long been a challenge, with fragmented insurance initiatives hindering efforts to achieve universal coverage. Recognizing the need for a cohesive and inclusive approach, the government took bold steps to consolidate various health insurance programs under the umbrella of the Philippines Health Insurance Corporations (PhilHealth). The creation of PhilHealth streamlined insurance programs. One of the key strategies employed was the digitization of payment of insurance premiums, making it easier for individuals to enrol and access insurance benefits. This initiative helped to overcome barriers such as bureaucratic inefficiencies and geographical constraints, particularly in remote areas.
THE FORWARD COURSE
Based on a market Study report commissioned by the Embassy of the Kingdom of Netherlands in Nigeria, Nigeria has 34,076 Primary Healthcare (which accounts for close to 90% of total hospitals in the country), across its 774 local government areas. Of this number, it was estimated that only 20% of the PHCs are functional, according to PharmAccess Foundation.
The Health System is at one of its lowest strengths fuelled by the current economic stress. The inflation makes getting care almost like a distant dream. Yet I still believe even though this is not the ideal time to plan for the health and social care needs of the populations, this is the best time to have every actor in the health system – health administrators, workforce, health techies, government, development organizations, CBOs & CSOs, health innovators, researchers, business-owners & entrepreneurs in the healthcare business to play their part towards the collective wellbeing of Nigerians. Perhaps we could do have a sovereign national conference for health or a regional conference like the African Climate Summit for Africa, something to reflects a State of Emergency for Health in Nigeria. At the moment, the vision of an equitable, climate-resilient health system cannot be achieved with the lacklustre effort put by those tasked with ensuring that the right to health for Nigerians are upheld.
A high performing health security in place to cater for the health and social care needs of citizen have several long-term outcomes from longer life expectancy to economic resilience and sustainable development owing to large scale productivity of all people.
To ensure the 2022 National Health Insurance Act achieves its goal of universal health coverage (UHC) in Nigeria, several deliberate interventions must be taken, as enlisted below.
Increasing Awareness and Education: A fundamental challenge such as the example of the LSHIS is low awareness among residents. Over 60% of respondents were unaware of the scheme’s existence, indicating a pressing need for aggressive statewide campaigns. Multichannel promotion initiatives, including radio, social media, and community outreaches, should be deployed to educate the public about the scheme’s benefits and encourage enrolment. A lot of innovations can come from co-creating programs with CBOs and CSOs who already at adept at community-led engagement when deploying their development interventions
Enhancing Affordability: Affordability is a significant barrier to enrolment, particularly with the economic crunch. There is need to develop innovative ways that will increase uptake of insurance products such as exploring innovative subsidy schemes that reflect economic realities, using embedded financing to ensure poor communities have access to health, flexible payment structures to mention a few.
Improving Healthcare Infrastructure and Service Delivery: Inadequate healthcare infrastructure and gaps in service delivery undermine the value proposition of picking up a health insurance plan. There is expectation that anything government, is likely to be substandard. Efforts should be made to expand the provider network, increase healthcare facilities’ accreditation, and enhance availability of medicines. Collaborating with private healthcare facilities and pharmaceutical companies can help bolster service offerings and improve access to quality care.
Streamlining Administrative Processes: The benefits of how streamlining the administrative processes helped improved the outlook of the insurance industry can be cultivated. Bureaucratic delays hinder smooth benefits access and discourage enrolment. No one is really interested in filling out hundreds of forms, we just want to get well. Embracing innovations around claims processing and customers’ complaint resolution with artificial intelligence could bring the needed ‘fresh air’ towards improving speed and convenience around service delivery.
Customers want to see that certain things change. We could also do more to improve on customers services aspects and the use of artificial intelligence with built-in advanced analytics capabilities to increase product satisfaction and improve service delivery for healthcare facilities. To this end, there is need for more workforce development program in the health sector.
Before we bother about level of coverage of health insurance for over 220 million Nigerians, how about we think about some foundational issues: How many States actually have a sustainable, strategic plan around a government-owned health insurance scheme? How many facilities are functional and are there plans to rehabilitate these facilities in line with the attainment of the universal health coverage (UHC)? How are we ensuring that the best minds are in the position to lead this movement towards UHC?
As I often hear it being said, contrarily to what people may think about the public sector, indeed the public sector needs even smarter people in administration compared to the private owing to the level of problems they are confronted by.