…as Rwanda, Botswana, Malawi, Niger, Zambia, others lead in health spending
A summary of a recent survey on the state of health insurance shows that Nigeria has sorely been lagging behind in health spending for its citizens. At the same time, the country has not done much to step up efforts to expand its existing health insurance scheme- the National Health Insurance Scheme (NHIS) – to cover more citizens in the country. Figures show that only about 5 million people have been covered by the NHIS. Besides, it took care of mostly workers in Federal Government ministries, departments and agencies (MDAs), leaving out the federating states – not to talk of the private and informal sectors.
Asoka, a medical doctor and a health insurance expert, at a recent media interaction in Port Harcourt, said there has been continuous decline in public (government) spending for health in Nigeria, relative to the needs of a growing population; there is very low allocation to health in government budget – what is released is even much lower than what is allocated; more than 60 percent of total health expenditure in Nigeria comes out of peoples’ pockets – ordinary Nigerians are main financiers of healthcare; fees required to be paid at health facilities deter large proportion of the population from accessing modern healthcare; typical household decision is divided between buying medicine for a sick child versus providing food for a day for the entire family.
Added to all these is that Nigeria’s budgetary allocation to the health sector has continued to drop, hardly exceeding six percent year-on-year. This is far less than the 15 percent budgetary allocation agreed by African countries at a health summit in Abuja, Nigeria in 2010, known as ‘Abuja Target.’ For instance, figures from the Budget Office of the Federation, Federal Ministry of Finance, show that between 1998 and 2012, health allocation as percentage of Federal Government budget hovered between 2.1 percent and 5.6 percent. This was only between 0.3 percent and 0.9 percent of the country’s Gross Domestic Product (GDP), whereas the highest federal budgetary allocation to health was N4.971 billion in 2011.
Meanwhile, countries like Rwanda, Botswana, Niger, Malawi, Zambia and Burkina Faso, little countries whose combined annual budgets can hardly match Lagos State budget, have surprisingly met or surpassed the Abuja Target by 2010. Rwanda led with 18.5percent budget allocation to health, followed by Botswana and Niger Republic at 17.9percent. Malawi stands at 17percent, Zambia 16.5percent and Burkina Faso, 15.9percent Nigeria comes far behind with a fickle 5.6percent. Comparatively, all six African countries – which have met or surpassed the target by 2010 – are considerably poorer than Nigeria. Amazingly, they have bigger health spending than a richer Nigeria – thought to be ‘giant of Africa.’
Asoka says, herein comes Health Insurance or similar pre-paid mechanisms – contributions ‘ring-fenced’ from further budgetary cuts, and provide financial risk protection for citizens. He propounded a working definition of health insurance in 2011 via Care Net Nigeria, a health publication that: “any approach that enables people to receive healthcare services or products without the need to pay for such services and products at the point of care, becoming a barrier to access.” In 1995, a maiden health summit in Abuja gave impetus to introduction of Health Maintenance Organizations (HMOs). These are: “insurance-based health systems that have the responsibility for the provision of a comprehensive package of care to an enrolled population for a prepaid fixed fee,” said Robinson and Steiner, in 1998. But the NHIS Act of May 1999 said a HMO is “…an institution, company or provident association using its administration or insurance companies to provide health care for its clients through associated health centres.”
According to Lekan Ewenla, publicity secretary of Health & Managed Care Association of Nigeria (HMCAN), an association of accredited HMOs, their role within the NHIS Act are: to collect contributions from all eligible employers and employees; collect contributions from voluntary contributors; render returns to the Council of the NHIS; contract with only health care providers approved by the Council; and ensure that contributions are banked according to guidelines approved by Council.
But how well are they performing these functions? Sadly, HMOs are fewer and only active in major cities of Lagos, Abuja and Port Harcourt. Few have equity participation from foreign entities – IFC, insurance companies, and some affiliated to commercial banks. Notable public HMOs are those of Defence ministry and Police.
Ewenla said NHIS is rather a formal sector programme. States are not included – the reason most state governments have yet to get on the programme. Some like Rivers have begun a Contributory Health Insurance program, outside the NHIS Act.
Benefit package excludes high-cost illnesses – like HIV/AIDS. Only generic drugs are given. The scheme covers employee, spouse and four children under the age 18. For working couples, their contributions cover both and not more than four children under the age of 18. For other dependants, the employee will be surcharged. Participants can enjoy services only after a waiting period of one month and are issued with Identity (ID) cards to minimise fraud. He said, contrary to NHIS Decree, HMOs act mainly as ‘third-party administrators’ to the public sector formal programme of NHIS.
Despite some gains, NHIS is inherent with challenges of poor wider coverage. There remains an urgent need to expand the scheme to cover states, private and informal sector. This is a major reason a new media advocacy team is in the offing, to raise awareness for a wider national health insurance. The team is in Lagos, Abuja and Port Harcourt.
