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By Eze Onyekpere
The National Health Insurance Authority Act of 2022 was enacted to repeal the National Health Insurance Scheme Act (2004) and to provide for the promotion, regulation and integration of Health Insurance Schemes in Nigeria and for related matters. The Authority is established as a body corporate with perpetual succession and an official seal. By S.2 of the Act, the objects of the Authority include the improvement and harnessing of private sector participation in the provision of healthcare services and ensuring that health insurance is mandatory for every Nigerian and legal resident. Furthermore, the Authority is to enforce the basic minimum package of health services for all Nigerians across all health insurance schemes operating within the country, including federal, states and Federal Capital Territory as well as private health insurance schemes. This discourse reviews the necessity of taking urgent and targeted steps to secure the buy-in of every Nigeria and legal resident to the new regime of mandatory health insurance.
Health insurance is linked to Universal Health Coverage. The goal of UHC includes ensuring that “all people can access quality health services, to safeguard all people from public health risks, and to protect all people from impoverishment due to illness, whether from out-of-pocket payments for health care or loss of income when a household member falls sick”. Full scale expansion of health insurance is pivotal to the attainment of the above goals. Improved health outcomes are hinged on the possibility of attaining UHC in that as more persons are covered, their basic health needs are met. Protecting people from the financial hardship of having to make out-of-pocket expenditure for health services reduces the risk of their sliding into poverty when unexpected ill-health necessitates using up life savings, selling assets, or even borrowing, etc.
In Nigeria, the enrolment numbers into the various plans of the former National Health Insurance Scheme (NHIS), now National Health Insurance Authority (NHIA) and various private health insurance schemes across the Federation is reported as follows in the NHIS Strategic Plan: “Currently, only about 4.2% of Nigerians are covered under the social health insurance. However, by virtue of expansion of state-supported health insurance schemes, this rate is projected to reach 8.8% by 2021 and 70% by 2030. Coverage growth of different population groups differ; the vulnerable and non-vulnerable groups’ coverage are expected to begin at 5% in 2021 and increase to 70% by 2030 while the non-vulnerable informal group has a slower coverage rate and reaches only 59% by 2030. The public sector and their dependents have coverage rate set at 68% by 2021 and is expected to increase rapidly to cover the whole public sector by 2025. With only 3% coverage rate by 2021, the private sector and their dependents have the lowest start-up coverage rate, however, their coverage is expected to grow rapidly to 80% by 2030”. Not much had changed in terms of the enrolment and access statistics since the Strategic Plan was drawn up in 2020.
Essentially, the legal provision for mandatory health insurance in Nigeria is a step in the right direction. Although ignorance of the law is not a tenable excuse or defence to the violation of binding legal provisions, it is imperative that addresses of the law, who have duties to perform and who are expected to take out health insurance for themselves and their families are informed of this relatively new development. They also need to be informed, sensitized and made aware of the available platforms, agencies and stakeholders who can facilitate their uptake of health insurance. This includes information on the available insurance packages, premium costs, options, what the individual stands to gain by subscription and payment of premium and the overall process for being part of a health insurance scheme. Arming the populace with this knowledge will facilitate the creation of new demand for health insurance services which will improve the movement towards UHC.
The expectation is that the Authority, state level health insurance authorities as the lead agencies need to devise and implement a multi-media, multi-stakeholder engagement strategy. This will involve the electronic (radio and television), print, digital and social media as well live face to face interactions with different stakeholders, geographic, population, professional, etc., groups. Special budget lines need to be utilized for this engagement while the federal and state authorities utilise the good offices of various civil society organisations working on health through their various outreach programmes.
Private sector support can also be mobilized through corporate social responsibility for health while health maintenance organisations that stand to benefit directly from increased health insurance uptake are nudged to invest in awareness creation and sensitization. Furthermore, the Authority needs to embark on advocacy visits, in collaboration with state health insurance authorities, to the respective governors and state Houses of Assembly to ensure the commencement of the of the public sector health insurance schemes across the states of the federation. This will involve contributions by the employers (state government) as well as contributions by employees (civil and public servants). Engagement of state level labour unions including the Nigeria Labour Congress and Trade Union Congress may be necessary to ensure the buy-in of workers. The take off of the public sector schemes will stabilize the scheme in each state and provide the muscle for the full engagement and mobilization of the organized private sector and the informal sector.
The imperative of this engagement is the background fact that between National Health Insurance Scheme years of 2004 to 2020 when the NHIS Strategic Plan was designed, only 5 percent of Nigerians held health insurance. This implies that two or more scenarios were working. The first is that there was little or no knowledge or information about the benefits and working of health insurance available to the populace. No one can engage a scheme he knows little or nothing about. The second applicable scenario was that the information and knowledge out there about health insurance was negative and instead of attracting new enrollees, scared away existing ones. Enrolment into the scheme and overall health insurance therefore stagnated.
Finally, the Authority and state level authorities need to reach out, to raise awareness, to sensitise, advocate and create necessary momentum that guarantees the respect of the mandatory provisions of the NHIAA.
Onyekpere writes from Lagos
