ABSTRACT
The healthcare delivery system in Nigeria like every other developing country is bedeviled with several issues and it has been proven that a National Health Insurance Scheme is capable of promoting and remodeling the condition of healthcare service in a country. This work aims to discuss the legal framework for the National Health Insurance Scheme (NHIS) in Nigeria considering its all-important functions and the near indispensability to the goal of achieving very affordable and proactive healthcare delivery system in Nigeria. The most important among the benefits of the scheme and all its offshoots is the provision of a readily available as well as a cost-effective access to good and very affordable healthcare services. This work shall conclude by providing suggestions by way of recommendations on how the NHIS can improve the healthcare delivery system in Nigeria which among others, is a need for a proper legal and regulatory framework that fit into the realities of Nigeria, bearing in mind the challenges which majorly is the lack of an adequate legal and regulatory framework which the Scheme currently faces in the country. This work employed a doctrinal research methodology as it engaged primary and secondary sources of law concerning the National Insurance Scheme in Nigeria and also acknowledging the views of writers, authors, assertions and contributions of various scholars which are relevant to the subject matter.
Keywords: National Health Insurance Scheme (NHIS), Healthcare delivery, Health Insurance.
Introduction
Most developing countries including Nigeria lack the ability to provide quality as well as affordable healthcare services to individual citizens, particularly middle –class citizens and the overly poor, who make up the largest portion of the world’s most populous Black nation, for obvious reasons. Citizens especially those in the rural areas do not have access to basic healthcare, a development that is even a violation of the inalienable rights of every citizen since everyone is entitled not only to easy access to a good healthcare system, but also an affordable one. The reason for this poor healthcare system in Nigeria is not far-fetched, chief among which is the very poor and very inadequate funding, others include, poor cost-recovery efforts; poor quality services; inequalities in healthcare provision; and widespread inefficiency in the system, among others.[1]
Health insurance is probably the most important but neglected aspect of health law and health care delivery in Nigeria, and attention is not usually paid to this area. There is lack of awareness of its importance in the country and even poor regulation of the system in Nigeria. This may also be linked to the neglect and subtle apathy of insurance and all that it represents in the country. Nigerians, especially the uneducated, and even some middle class members, tend not to focus on, or rather believe in, insurance at all, how then would they believe in health insurance?
As a result of the poor healthcare delivery system in the country due to financial inadequacies, among others, the government has institutionalized the National Health Insurance Scheme established by the National Health Insurance Scheme Act[2] to make healthcare accessible and affordable to all Nigerians. This National Health Insurance Scheme involves a prepayment health scheme established by the Government of the country to provide insurance with a national outlook and which, if subscribed, gives members easy access to the provision of health care services as soon as possible.
the benefits on the benefits of the NHIS and discuss the challenges faces by it in delivery of healthcare in Nigeria. This work aims to suggest recommendations which would aid in the attainment of the goals and potentials of the NHIS.
Healthcare Delivery System in Nigeria
The healthcare delivery system in Nigeria is impoverished with a lot of disheartening problems. The healthcare system faces inadequate coverage, as many Nigerians, particularly those in rural communities, are not well served and do not yet have access to quality modern healthcare services.[3]
The delivery of healthcare in Nigeria is driven by both the public and private sectors. The public healthcare system consists of the federal providers consisting of tertiary teaching hospital that offer specialized care, state providers that manage various general hospitals at state level and local government providers that provide care through local primary healthcare centers. However, the system operates in such a way that the three levels of government have similar responsibilities for providing healthcare services.[4]
The intervention of the private sector is in the form of privately owned health insurance outfits, which are also mostly sponsored by corporate private concerns through the usual insurance service in exchange for healthcare.[5]
What Is National Health Insurance Scheme (NHIS)?
Health insurance is essentially a social security mechanism that ensures the provision of necessary health services to individuals by paying a certain amount at regular intervals.[6] It is designed to pay the costs of healthcare by paying the bills and therefore protect people from high healthcare costs by making payment in advance of falling ill.[7] Health insurance is a pooling of health risks in order to provide benefits to participants due to uncertainty underlying the occurrence of ill-health and to the payments for the treatment of such ill-health.[8]
Insurance is a healthcare financing tool that comes in different models, and many countries use these different models to fund healthcare. Evidence shows that insurance is a useful and sustainable means for financing the healthcare structure and delivery world-wide[9]. The scheme as stated above is the creation of the government to protect individual citizens from financial hardships occasioned by large or unexpected medical bills due to the unpredictability of our physical and mental well-being and the general health status of each individual at any given time. It is the government’s responsibility to provide a system to ensure a healthy nation where all citizens enjoy the facility it has set up to provide good health services, as the cliché remains that a healthy nation is a rich nation.[10]
The National Health Insurance Scheme (NHIS) is a body corporate with a common seal and perpetual succession capable of suing and being sued in its corporate name constituted under Section 1 of the National Health Insurance Scheme Act[11] y the Federal Government of Nigeria to improve the health of all Nigerians at an affordable cost, among others.
The vision of the National Health Insurance Scheme (NHIS) includes a strong dynamic and responsive government that is fully committed to ensuring universal coverage and access to adequate and affordable healthcare, in order to improve Nigeria’s health status, particularly for those participating in the Scheme’s different programs or products. The mission of the Scheme is to promote equal financing of healthcare costs by pooling and judicious use of financial resources to provide financial resources to provide people with financial risk protection and cost-sharing, against rising healthcare costs, through various pre-payment programs/products before they become ill. This is in addition to providing the Health Maintenance Organizations (HMOs) and participating Health Care Providers (HCPs) with regulatory oversight.[12]
The objective of the National Health Insurance Scheme (NHIS) includes;
- Ensuring access to good healthcare facilities for every Nigerian
- Shielding amilies against the financial hardship of enormous medical bills
- Limiting the cost of healthcare services
- Ensuring a fair distribution of healthcare costs among different income classes.
- Maintaining high standards of health care delivery services within the context of the Scheme
- Ensuring productivity in healthcare services
- Improving and harnessing the role of the private sector in healthcare services
- Ensuring that health facilities are distributed equitably within the Federation
- Ensuring adequate patronage of all levels of healthcare
- Ensuring the availability of health sector funding for improved services.[13]
There are many models of insurance scheme which include Social Health Insurance (SHI) which focuses on solidarity-based health insurance which relates to contribution of income.[14] This is usually administered by public bodies, which is compulsory and Private health insurance (PHI) which can be taken up and paid for at the discretion of individuals or employers on behalf of individuals, which is voluntary and both of them have different modes of operation.[15]
There has been a clamour for Social Health Insurance (SHI) in Nigeria that has been found to be more successful than Private Health Insurance (PHI) in developing countries. This has led to the birth of the National Health Insurance Scheme. In order for Social Health Insurance (SHI) benefits to be properly realized in the country, there must be considerable stability within the political matrix upon which it will operate relevant mix of human resources for health, acceptance of concept of social solidarity, adequate health infrastructure to deliver quality health services, and the existing appropriate legal and regulatory framework, among others.[16]
It should be noted that the National Health Insurance Scheme is a peculiar financial mechanism for the provision of healthcare delivery service, as it is based on the Social Health Insurance (SHI) system. The Social Health Insurance is a system that was introduced in Nigeria in 1999 and focuses on solidarity-based health insurance, which relates to contribution of income[17].In essence, solidarity is the key attribute of the National Health Insurance Scheme. The idea behind the National Health Insurance Scheme is to avoid certain disastrous situations that may arise as a result of unexpected fatal illnesses (or even minor illness) with catastrophic consequences in the country, in other words, to protect people from the ruinous financial consequences of illness. The writer’s emphasis on this scheme gives a scenario that goes as follows:
Kayode was diagnosed with cancer. Later, his situation worsens and he suffers from a collapse and is placed on a ventilator, it should be noted that Kayode is not covered by any health insurance policy. Kayode who was placed on a ventilator, has not recovered and is not on the verge of dying but the hospital intends to disconnect him from the ventilator, which would cause Kayode to die.
The reason for this is that Kayode who is not covered by a health insurance policy has no means to pay for further treatment and as a result, the ventilator is disconnected and he dies.
From the above scenario, on the part of the hospital or medical practitioner involved in the act, the removal of the ventilator could be an illegal act (in the case of Nigeria) and subject the hospital or the medical practitioner to the possibility of legal action, but assuming that Kayode was under a health insurance policy, the whole situation of disconnecting him from the ventilator would not have occurred, as his health insurance would have covered for his continuous placement on the ventilator , and this would not have resulted to his immediate death, as well as the hospital or medical practitioner facing possible prosecutions. Health insurance is therefore very necessary for the lives of all individuals and for the country as a whole, if anything, it helps to boost life expectancy and gives us a healthy nation with a very low mortality rate coupled with a responsive healthcare delivery system, which appears to be the objective of the National Health Insurance Scheme as constituted.
The National Health Insurance Scheme (NHIS) is institutionalized for the purpose of attracting more resource to the health sector and thus improve the level of access and utilization of healthcare delivery services in the country. However, whether this purpose or objective will work and whether the current model of the National Insurance Scheme (NHIS) is viable is a matter of concern.[18]
The National Health Insurance Scheme is designed to make each individual in the country to indirectly save toward unforeseen health challenges.
The Regulatory Framework for the National Health Insurance Scheme (NHIS) And Its Challenges.
The regulatory framework for the National Health Insurance Scheme (NHIS) is the National Health Insurance Scheme Act (NHIS) Act[19]which was promulgated as a result of the poor delivery of healthcare services in Nigeria by the federal government of Nigeria.
The first attempt to build a healthcare system was in 1962, when the federal minister presented the bill to the parliament for its promulgation in Lagos at that time. Unfortunately, there was a disagreement on this bill from the Nigerian Medical Association. In 1988, the then minister of health commissioned a committee that recommended a template for the present day National Health insurance scheme.[20] Due to the unbalancing feature of the of Nigeria lawmakers, the law that established the scheme was signed in May 1999 but became operational in June 2005 after it was dormant for almost six years.[21]
Section 1 of the National Health Insurance Scheme Act[22] establishes the National Health Insurance Scheme and states that the purpose of the scheme is to provide health insurance to entitle insured persons and their dependents to benefit fromrescribed good health and cost-effective health service. Section 5 of the same Act sets out the objectives of the scheme established by this Act which has been identified above by the writer and includes ensuring access to good health care services for every Nigerian, protecting families from the financial hardship of huge medical bills, ensuring equitable distribution of health care costs among various income groups among others.
Section 6 of the National Health Insurance Scheme Act[23] vests on the National Health Insurance Scheme the power of registering health maintenance organization and healthcare providers under the scheme, Health Maintenance Organizations (HMOs) are set out by the National Health Insurance Scheme to observe and address shortcomings in the quality of health care service delivery, these organizations serve as a model in which the NHIS use to fund healthcare,[24] while Healthcare Providers (HCPs) include a licensed government or private health care practitioner registered under the approved health benefit scheme for contributors and their dependents.[25] Section 6 of the Act also vest on the scheme the issuing of appropriate guidelines for the viability of the scheme, determining, after negotiation, capitation and other payments due to health care providers, by the health maintenance organizations, advising the scheme on the quality of health service to improve the scheme among other. In general, the scheme is controlled by the government.
This Act provided for a council under Section 2[26] which is responsible for ensuring the effective implementation of the policies and procedure of the scheme, responsible for ensuring public awareness of the scheme as well as coordinating manpower training under the scheme among others[27].For the purpose of reviewing the Scheme and evaluating it actuarially, including the rates of contributions payable under the Scheme and make appropriate recommendations to the Council, the council is given the power to appoint a licensed actuary on such terms and condition has may be determined by the council.
The provision of Section 17 of the National Health Insurance Scheme Act[28] provides for funding of the Scheme which is gotten from the wage- related contributions shared between the employers and their employees depending on the type of health care service they may require. These contributions are paid through the designated Health Management Organizations (HMOs) into a fund established under Section 11 of the Act for that purpose.[29] This contributions cover health care benefit for the employee, a spouse and four biological children below the age of eighteen years and where such employee intends to cover more member of his family or dependents or a child above eighteen years, then additional contributions will be made different from the general contribution.[30]
Over the years, the NHIS had expanded its scope and currently operates the following schemes; formal sector health insurance programme, informal sector health insurance programme and vulnerable health insurance programme. By virtue of Section 16(1) of the National Health Insurance Scheme Act (NHIS)[31], the scheme covers any employment in which the employers have a minimum of ten employees in his employment. This basically implies that the scheme in principle is restricted to employees in the services of the Federal, State, and Local Governments as well as private sector organizations having at least a minimum of ten employees, it also covers members of the Armed Forces, the Nigeria Police Force, the Nigeria Customs Service and the Nigeria Immigration Services. However, Section 17(3) of the Act[32] gives allowance for those not ordinarily covered by the scheme to register as voluntary contributors.[33] Section 11 of the Act provides for other means which the National Health Insurance Scheme are funded.
In order to ensure efficient and effective health care delivery service and to achieve the commendable objectives of the scheme, the National Health Insurance Act adopted a model by employing the service of Health Maintenance Organization (HMOs) who as stated above are private and public insurers registered under Section 19 of the Act, they serve as managers and are charged with the duties under Section 20 of the Act. They contract with Health Care Providers (HCPs) who are approved by the council of the National Health Insurance Scheme to render health care service.
From the following provision, it is obvious that this scheme is more favored to the formal sector health insurance program in Nigeria than to the informal sector health insurance program as well as the vulnerable health insurance programme which includes the self – employed individuals in the country; those in the rural communities; the permanently disabled; aged; children. These are considered to be one of the challenges of the National Health Insurance Scheme as the focus which is placed on the formal sector cannot be said to be in tune with the objective of the Scheme which is meant to ensure that “every” Nigerian has access to good health care service and not every individual in the formal sector and also to protect families from the financial hardship of huge medical bills and families includes every single Nigerian and their families and not just the individuals in the formal sector and their dependents. It is therefore important to identify the challenges of the National Health Insurance Scheme Act in Nigeria; hence, the shortcomings of the National Health Insurance Scheme.
The challenges have been identified to be;
Lack of Awareness
One of the reasons National Health Insurance Scheme is failing in providing quality healthcare service in Nigeria is because many Nigerian are not aware of the existence of this Scheme especially those in the rural areas. Some of the Federal workers, for instance, the Nigerian Immigration Service do not even know about the existence of the Scheme which is supposed to cover them. Nigerians are not interested in knowing or buying the idea of the scheme[34] and to this writer, this is not their fault as awareness of the benefit of the scheme and health insurance is not created, no emphasis is being laid to encourage health insurance and this makes this set of Nigerians have a negative dogmatic idea about the scheme.
Enforcement
It is a well-known fact that Nigeria is not really suffering from absence of laws and regulations governing our lives, but our problem lies in the implementation of these existing laws. There is a marked difference in the application of the laws and practice of the laws as provided in the Act for the operation of the National Health Insurance Scheme. In the Leadership Newspaper, it was stated that the National Health Insurance Scheme after 15years covers only two percent of Nigerians.[35]
Inadequate Legal Framework
The provisions of the Act itself are a cause of the inability of the scheme to attain its objective. It consists of a copy and paste methodology from other countries and so this does not seem to be in tune with the reality of the country. The Act makes it mandatory for only Federal employees and private sector businesses with ten (10) or more employees to register with the scheme and voluntary for others, this makes the National Health Insurance Scheme to be for a selected few. Also, the Act provided for some excluded service from the NHIS service such as occupational and industrial injuries, epidemics, injuries from extreme sports, drug abuse addiction, provision of hearing aids, high cost surgical procedure such as organ transplant;[36] this should not be so.
It has been observed that the NHIS is basically employment-related with the option of voluntary participation given to other segments of the population unlike in Ghana where the NHI is strictly on solidarity terms which makes healthcare service accessible to all especially to the vulnerable and marginalized groups including women, children, older persons and persons with disabilities; the NHIS Act does not make any explicit provision for the poor, the aged and other vulnerable groups with limited means who need assistance more than any other[37]and as such very little of the population in Nigeria is covered.
Lack of adequate funding
The health sector generally suffers from issue of funds. The inadequate allocation of funds to the all-important health sector is affecting the National Health Insurance Scheme. There are no enough funds for the National Health Insurance Scheme to carry out its objective and this is the actual reason why the scheme focus on the formal sector as there is no funds to cater for the informal sector for instance the unemployed, the vulnerable citizens who cannot afford to work and pay contribution themselves.
Cultural Orientation
Another challenge to the NHIS is the superstitious thought some Nigerians have, they believe when they prepare for an illness which they do not have, it means to them that they are wishing for themselves such illness; this superstition belief revents many Nigerians to register with the scheme. Some question its contributory nature, believing that it is the total responsibility of the government to take care of the health needs of its citizens.
This set of people do not understand the concept of solidarity and the concept of being your brother’s keeper and this is because in Nigeria, the situation of the country in general makes Nigerian to only care about themselves; there is no sense of selflessness among Nigerians
Recommendations
The National Health Insurance Scheme has the potentials to transform healthcare delivery in the country. Therefore, it is important for the following recommendation to be made in order to have a viable and all-encompassing scheme.
- For awareness of the National Health Insurance Scheme, there should be proper sensitization of individuals in the country and this can be done through frequent publications of the benefits and operation of the scheme, public enlightenment on radios, televisions station. A committee could be set up specifically for going to various communities to explain the importance of the scheme and reason why every individual should be covered.
- In order to ensure proper enforcement of the scheme, all cumbersome provisions and restrictions should be scrapped so as make implementation easier and the available provisions should be modified for it to fit into the reality of the country.
- More funds should be allocated to the health sector. Health is very crucial and the wellbeing of the citizens should be of utmost importance, therefore, it is important for the government to give more attention and not just rely on the pay roll contributions by employers and employees.
- There should be an expansion of the scheme to cover further health challenges. A survey in different communities in the country should be carried out by a committee formed for that purpose to discover the emerging and endemic health issues faced by several citizens as this would ensure a better coverage.
- The National Health Insurance Scheme should be made compulsory for all citizens in the country and not just compulsory for employers and employees, this will ensure the participation of every citizen and will ensure participation of the stubborn citizens whose mind have been colored with their superstitious believe of health insurance.
- It is necessary for more attention to be paid to the informal sector and also the scheme should be made mandatory for all sectors and not just the formal sector, this will enable focus on all citizens.
Conclusion
The National Health Insurance Scheme is very capable of remodeling the condition of the healthcare delivery in Nigeria but for this to occur, there has to be a proper regulatory framework which will be in tune with the realities of the country. It is important for the Scheme to reach across all Nigerians in order to meet its purpose and to ensure a better existence for all persons in the country, while the National Health Insurance Scheme has so many potentials, it will only achieve its desired goal/vision when the challenges which have been identified are looked into.
About the Author
Raji Sekinat Olasumbo is a 500 Level Law Student, Afe Babalola University, Ado-Ekiti, Ekiti State; ACArb; Email: [email protected]
References
[1] Obinna Onwujekwe and Benjamin Uzochukwu and Ibe Ogochukwu and Nkoli Uguru, ‘Health Insurance: principles, models and the Nigerian National Health Insurance Scheme’ [2012] (1118-2601) International Journal of Medicine and Health development. <https://www.researchgate.net/publication/315055646> accessed 16 November 2019.
[2] Cap N42, LFN 2004.
[3] Obinna Onwujekwe and Benjamin Uzochukwu and Ibe Ogochukwu and Nkoli Uguru, ‘Health Insurance: principles, models and the Nigerian National Health Insurance Scheme’ [2012] (1118-2601) International Journal of Medicine and Health development. <https://www.researchgate.net/publication/315055646> accessed 16 November 2019
[4] Ibid.
[5] Ibid.
[6] Toyin Adefolaju, ‘Repositioning Health Insurance in Nigeria: Prospects and Challenges’ [2014] (2) (2372-5060) International Journal of Health Sciences; 151-162.
[7] Ibid.
[8] Obinna Onwujekwe and Benjamin Uzochukwu and Ibe Ogochukwu and Nkoli Uguru, ‘Health Insurance: principles, models and the Nigerian National Health Insurance Scheme’ (2012) (1118-2601) International Journal of Medicine and Health development. 3> accessed 16 November 2019
[9] Eno Usoroh, ‘Achieving universal health coverage in Nigeria: The National Health Insurance Scheme as a tool’ (Unpublished MPH Thesis, Free University of Amsterdam (VU) Amsterdam, The Netherlands, 2012) ; xii
[10] Augustine A. Inyang and Francis A. Bassey, ‘National Health Insurance Scheme in Nigeria: Impact on Healthcare Delivery System in Nigeria” [2018] (2) (2456-7760) International Journal of Economic, Business and Management Research; 481-492.
[11] Cap N42, LFN 2004.
[12]National Health Insurance Scheme Operation Guidelines [2012].
[13]National Health Insurance Act Cap N42 LFN 2004, s5
[14] Ijeomah, Arodiogbu, ‘Introducing Social Health Insurance to Solve Problems of Poor Health Sector Financing in Nigeria’ (Unpublished MHA Thesis, The University of Leeds, 2005). 2
[15] Ibid.
[16] Obinna Onwujekwe and Benjamin Uzochukwu and Ibe Ogochukwu and Nkoli Uguru, ‘Health Insurance: principles, models and the Nigerian National Health Insurance Scheme’ [2012] (1118-2601) International Journal of Medicine and Health development. <https://www.researchgate.net/publication/315055646> accessed 16 November 2019
[17] Ijeomah Arodiogbu, ‘Introducing Social Health Insurance to solve problems of poor health sector financing in Nigeria’ (Unpublished MHA Thesis, The University of Leeds, 2005) 2.
[18] Obinna Onwujekwe and Benjamin Uzochukwu and Ibe Ogochukwu and Nkoli Uguru, ‘Health Insurance: principles, models and the Nigerian National Health Insurance Scheme’ [2012] (1118-2601) International Journal of Medicine and Health development. <https://www.researchgate.net/publication/315055646> accessed 16 November 2019
[19] Cap N42, LFN 2004, initially enacted as National Health Insurance Scheme Act 35, 1999
[20] Health Insurance, ‘History of Health Insurance in Nigeria’ Available at <https://www.ehealthinsurance.com.ng/history-of-health-insurance-in-nigeria/> accessed 29 January 2020
[21] Ibid
[22] Cap N42, LFN 2004.
[23] Cap N42, LFN 2004.
[24]James O. Akinbode and Eniola A. Sokefun, and Muideen O. Aremu, ‘Appraisal of Health Maintenance Organisations Performance in the Nigeria Healthcare Service Sector’[2019] (Volume 2019) (Article ID 6820609) Journal of Healthcare Engineering ; 1
[25]Adebambo Ladeyin., ‘Implementation and Challenges of National Health Insurance Scheme in Obafemi Awolowo Health Centre (Unpublished Thesis, Faculty of Social and Administrative Pharmacy, 2016); 64
[26] National Health Insurance Scheme Act Cap N42, LFN 2004.
[27] National Health Insurance Scheme Act Cap N42, LFN 2004, s7
[28] Cap N42, LFN 2004.
[29]Kehinde Anifalaje, ‘Legal Framework for National Health Insurance in Nigeria and Ghana: A Comparative Analysis’. [2014] (Volume VI), (1115-1277) A Journal of Contemporary Legal Issues; 173-208.
[30]Ibid.
[31] Cap N42, LFN 2004.
[32] National Health Insurance Scheme Act Cap N42, LFN 2004.
[33] Kehinde Anifalaje, ‘Legal Framework for National Health Insurance in Nigeria and Ghana: A Comparative Analysis’. [2014] (Volume VI), (1115-1277) A Journal of Contemporary Legal Issues; 173-208.
[34] Toyin Adefolaju, ‘Repositioning Health Insurance in Nigeria: Prospects and Challenges’ [2014] (2) (2372-5060) International Journal of Health Sciences; 151-162.
[35] Patient Ivie, ‘15 Years After, NHIS Covers only 2% of Nigerians’ Leadership Newspaper (Nigeria,29 January 2020) < https:/./leadership.ng/2020/01/29/15-yrs-after-nhis-covers-only-2-of-nigerians/. >accessed 29 January 2020.
[36] Agunobi C. Ohalete, ‘Management of National Health Insurance Scheme (NHIS) in Nigeria’ (Unpublished MBA Thesis, University of Nigeria, 2008); 40.
[37] Kehinde Anifalaje, ‘Legal Framework for National Health Insurance in Nigeria and Ghana: A Comparative Analysis’. [2014] (Volume VI), (1115-1277) A Journal of Contemporary Legal Issues; 173-208.