Friday 10 April 2009 - 02:05:02

dr with female child pts.jpgBy Dr Dotun Adesina


In 1990, total health spending ranged from less than $10 per capital in several African and Asian countries to more than $2,700 per capital in the U.S.A. As a result of this, the ability of government especially in the 'developing nations', to implement their health policies, strategies, programmes and projects has been greatly affected. This chronic underfunding of the health sector makes it increasingly difficult for the public sector to provide health services for its populace in most part of the developing nations. The achievement of the Millenium Development Goals (MDGs) is also becoming bleak due to inadequate funding.

In Nigeria, the health sectoris principally financed by the government. The government is faced with various challenges- a stagnant mono-cultural economy that depends on crude oil as a single export commodity, a rapid population growth, political instability and high rate of unemployment. Hence, the government cannot afford to commit enough money to the health sector which is now faced with the consequence of underfunding- decreased efficiency, decreased quality/quantity of service, diminished confidence in public sector health facilities and poor maintenance of equipment. An alternative source of health financing is thus inevitable if our vital health indices in Nigeria will not continue to deteriorate; hence the evolution of the National Health Insurance Scheme in Nigeria. Health Insurance is a means of spreading the risks of incuring health care cost over a group of individuals and households. Healthcare costs are often unaffordable to individuals if they have to pay the full cost of treatment as it occurs. Health Insurance is the pooling of resources by groups of individuals to take care of such needs. It entails risk sharing by contributors, thus individuals with higher resources subsidise those with less and those with low incidence of illness subsidise those who require care more frequently. Health Insurance is defined as the ability to get health services when required without having to pay fully at the time of need because payment has been made by a fixed regular contribution by the insured or his/her employer or both (prepayment plan). The money is pooled by the provider of the insurance to pay for all those needing health care. The other alternative to health insurance is the out of pocket payment at the point of service delivery which has been on in Nigeria for decades. "Out of pocket" payment is the least desirable means of health care financing as it denies access to healthcare to those who cannot afford to pay at the time of their illness. Prepament schemes appear to offer a better healthcare financing option than "out of pocket" schemes. The elimination of "out of pocket" payment option is the goal of health insurance. Health insurance is now regarded as probably the most common form of financing healthcare worldwide. HISTORICAL BACKGROUND Among the industrialised countries, insurance can be traced back to the time of their developing era. Pooling of resources by groups of individuals in order to protect themselves against certain types of adversity such as disability and sickness can be traced back to the 11th and 12th centuries. In European cities, funds were built by guilds from periodic contributions of their members and the money used for members facing problems such as illness. Later in the 18th and early 19th centuries, factory wage earners replaced independent artisans, they formed groups in particular industries and certain localities and called the organisation - 'Sickness Funds'. This insurance idea grew in thousands in Europe in the late 19th century. In 1983, German Chancellor Bismarck enacted a law requiring all workers with wages less than a certain amount to benefit from social insurance. This marked the birth of Social Security Movement. Similar development followed in Austria, Hungary, Great Britain and the Scandinavian Countries. By 1927, all industrialised countries of Europe had followed suit including France although the the range of population coverage and health service benefits differ from country to country. In Africa, Algeria in 1949 adopted a statutory health insurance programme, followed by Libya in 1957, Tunisia in 1960 and Egypt in 1067. Guinea was the first to establish social security for health care in Sub-Saharan Africa. The First attempt at adopting an health insurance system in Nigeria started in 1962 during the First Republic. The Federal Government invited Dr Halevi through the International Labour Organisation (ILO) to look into starting a health insurance system in Lagos. The then Minister for Health Dr Majekodunmi also presented the first bill to the parliament. The Nigerian civil war years caused the matter to be shelved but was resuscitated by the health council in 1984 when a committee was commissioned to study the National Health Insurance. In 1988, Professor Olikoye Ransome-Kuti commissioned the National Committee on Establishment of the NHIS, chaired by Emma-Eronmi. In 1989, Eronmi committee report was submitted and approved by the Federal Executive Council. The United Nations Development Programme (UNDP) and International Labour Organisation (ILO) consultants conducted their own studies in Nigeria to provide costing, draft legislation and implementation guidelines for establishing the NHIS in 1992. The Federal Executive Council which had given its approval in 1989 directed the Federal Ministry of Health in 1993 to start the scheme. In 1999, the enabling decree - Decree 35 was promulgated - May 10, 1999. On the 6th of June 2005, the fomal sector of the social health insurance scheme was flagged off by Chief Olusegun Obasanjo the then president of the Federal Republic of Nigeria. As at today, the scheme has covered all the Federal Ministries, Parastatals, Agencies, the Nigerian Police and Armed Forces. It is also firmly established in the organised private sector. OBJECTIVES The objectives of the NHIS are mainly 1) To ensure that every Nigerian has access to good healthcare services. 2) To solve the problem of inappropriate use of levels of healthcare, leading to unnecessary cost and under-utilization of specialized facilities ensuring equitable patronage of all levels of health care. 3) To improve and harnes private sector participation in health care service delivery and to ensure institutional quality assurance. 4) Protect families from the financial hardship of huge medical bills 5) To ensure equitable distribution of healthcare cost among different income groups 6) Limiting the rise in the cost of healthcare service 7) To maintain high standard of healthcare delivery services within the scheme. 8)To ensure availability of funds to the health sector for improved services and foster research in the health sector. 9) To ensure efficiency in healthcare services 10) To ensure adequate distibution of health facilities within the federation. BENEFITS OF THE SCHEME The benefits derived from participation in the scheme are defined by law and include; • Hospital in-patient and out-patient care • General practitioner services in the communities • Physician specialist services • Medicaments • Ancillary Services such as X-Ray, Laboratory tests • Vision test and spectacles • Prostheses, appliances and rehabilitation • Basic dental maintenances • Reconstructive dental care • Preventive care including immunisation, family planning, ante-natal care, post -natal care and health education TYPES OF HEALTH INSURANCE SCHEME 1) Private:- This is through employer-owned on-sight health facilities or through contract with outside providers. Private health insurance individuals (volunteers, privately imployed) are catered for by agencies. It is devoid of ristk sharing, benefits are not as of right. The measure given by the individual or the employer is the same measure of service received. Benefits are not uniform, contribution payable is based strictly on the need of individual i.e the higher the health needs of the contributor, the higher the payment. 2) Social:- Payment is irrespective of needs and is usually based on employment and income. It is a form of payroll tax sharing between employers and employee earmarked to pay for health care. It is based on solidarity. Resources are pooled together among large population and it enhances security of each individual in the group. 3) Community Sponsored Insurance:- A community based programme which normally operates in the rural areas and mostly localised. It is co-ordinated and organised by cooperative societies, unions and non-governmental organisations. An example is the Country Women Association of Nigeria (COWAN) a rural co-operative union which has operated a credit-linked Halth Dvelopment Fund (HDF) since 1989. The overall goal of this laudable scheme is to provide access to qualitative health care to the teeming population of Nigerians at an affordable cost and least possible inconvenience. The success will thus depend on popular understanding and implementation on the part of everyone that is involved in the scheme. The client (the subscribed population), the care-giver (professionals in the health sector), the health maintenance organisations (the managers of the scheme)and the NHIS secretariat ( the umpire) will have to protect the scheme from the corruption bug in Nigeria as it gradually evolves into a formidable force in providing alternative to health care funding in NIgeria. We hope to contribute to this success by ensuring a proper understanding among all players and by periodic appraisals of the scheme. Offer your suggestions on ways by which the scheme can be fine-tuned and further strengthened. HOW THE SCHEME OPERATES IN NIGERIA There are five major stakeholders in the scheme: a) Employer b) Employee c) Primary Care Providers - Primary and Secondary d) Health Maintenance Organisations - Operators of the scheme e) Government Agency (NHIS) - Regulator of the scheme. For participation in the scheme, contributors will first register with an NHIS approved HMO and thereafter register with a primary health care provider of their choice from an approved list of providers registered by their HMO. The contributor and his/her dependants are issued ID cards on registration. In the event of sickness, he presents to his chosen Primary Care Provider (PCP) with his ID card. A contributor has the right to change his PCP after a minimum of six months if he is not satisfied with the services there. A contribution made by the insured person entitles his or her spouse and four children under the age of 18years to full health benefits. However, students in school up to the age of 25 years qualify as dependants. Extra contribution will be required for additional dependants. Contribution to be made by formal sector employees for health benefits under the scheme will be 15% of wages, the payment of which will be by both the employee and the employer. The employee pays 5% while the employer pays the remaining 10%. The employee's part of the contribution is deducted from his pay with the employer adding the remaining and forwarding the total payment to the appropriate quarters - HMO and NHIS. The implementation of the scheme will be in phases to cover all Nigerian Organised as follows; • Employers in the formal sector (Public and Private). Their contribution will be paid by their employers and those in public sector by the Federal, Sate and Local Government. Parastertals, ministries and agencies as appropriate. • Self employed person (market women, traders, artisans, farmers, business men etc.). They will be encouraged to pay their contributions either by themselves or through co-operative bodies formed by them. • Employer of labour with ten or more workers in their establishment are to subscribe to the scheme and make contributions for their employees as aforementioned. • Rural dwellers- These group will enjoy suitably tailored programmes designed for them which will be implemented in consultations with various organisations like banks, co-operatives, donor agencies, NGOs, local, state and federal governments. • Vulnerable groups which include the unemployed, the aged, the disabled, the street children, retarded children and retirees. Their contribution is expected to be made by the Federal, State and Local governments, NGO, local communities and philantropists. The implementation of this coverage plan is however expected to be in phases. As it is today, only the employees of Federal Government ministries, agencies, staff of the Nigerian Police Force,Ngeria Army and employees of the organised private sector enjoy the scheme in Nigeria. STRATEGIES/IMPLEMENTATION ACTION POINTS IN NIGERIA Reservations have been expressed regarding the public sector's capacity to manage such an administratively cumbersome scheme, given the poor performance of most public enterprises such as the National Housing Fund and Natioanl Providence Fund. In the evolution of the National Health Insurance Scheme therefore, recognition of inefficient and inappropriate use of resources as prevalent and recurring problems in the health sector informed the decision to make the scheme private sector driven. This private sector participation is expected to enhance financial probity and effective management. The function of the HMOs include; • Collection of contributions from eligible employers adn employees • Collection of contributions from other contributors • Payment of health care providers fro services rendered. • Maintenance of quality assurance in the delivery of the health care benefits under the scheme. Private or public individuals/establishment may form these organisations which are limited liability companies solely formed for the purpose of provision of health services and registered under the scheme. Health care providers are primary and secondary in category. The primary health care providers are the gate keepers. They will serve as first contact with the care system. They include: - Private clinics/hospitals - Primary health care centres (private or government) - Nursing and maternity homes (overseen by doctors) - Outpatient departments of General, Specialist and Teaching Hospitals. Payments for services rendered by these providers to contributors is by capitation. Capitation is a predetermined sum of money paid by the HMO on behalf of a contributor for services rendered by the provider. This payment is made monthly whether the services are used or not. Secondary health care providers include Specialist doctors, pharmacists, laboratory scientists, radiographers, physiotherapists and dentists. They provide services to the contributors on referal from the primary health care providers. Their payment is made by HMOs on a fee-for-service basis.


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