On Thursday 19th of May, 2022, the President of the Federal Republic of Nigeria announced that he had signed a new National Health Insurance Authority Act 2022 into law. The new law repealed the National Health Insurance (NHIS) Act of 2004, which had introduced the concept of National Health Insurance to Nigeria.
The concept, recognised as the only realistic way of getting the generality of Nigerian citizens to have access to good, standardised healthcare, had not, in nearly twenty years since its inception, seen the enrolment of a significant proportion of the population.
For a scheme that was meant to scale up rapidly to cover the entire population, only 13.5 million Nigerians, out of a population of over 200 million, had enrolled on the National Health Insurance Scheme as at the end of December 2021.
This idealistic mindset and the sense of entitlement it engenders in the citizens has, paradoxically, been one of the major stumbling blocks in the way of attaining good, accessible health service for all the citizens of Nigeria
Ensuring the health of a people is, of course, larger than the delivery of healthcare to the ailing. On the list of the 17-item ‘Sustainable Development Goals’ targeted by the United Nations for the nations of the world to attain by 2030, health is only one item. However, virtually every other of the seventeen items has a bearing on the health of people, and vice versa. The well-being of human beings is affected by the liveability of the environment, and such factors as the quality of housing, the amount of time the citizen spends in traffic commuting from home to work every day, the quality of the water he drinks, and several other factors.
Having said all that, the availability and accessibility of good quality healthcare services to the citizens is crucial for their wellbeing.
Traditionally, Nigerians have tended to see Healthcare as a social service that is meant to be delivered free by government to the citizens. This idealistic mindset and the sense of entitlement it engenders in the citizens has, paradoxically, been one of the major stumbling blocks in the way of attaining good, accessible health service for all the citizens of Nigeria.
The UPN government of Dr Lateef Jakande in Lagos made ‘Free Health’ a cardinal part of its agenda, and strove with exceptional diligence to implement it.
The governments that came after it made some vague efforts to continue the tradition. One of the practical expedients resorted to was reducing the coverage of ‘Free Health’ to children under twelve years old. Somehow the numbers never added up, even then.
There was never enough of everything to guarantee the unhindered rendering of health services in a sustainable way to every member of society who needed or demanded it. ‘Free Health’ was a mirage that looked romantically attractive politically and appeared to be a God-given entitlement of the citizen. The reality of health, unfortunately, is that nothing is free. Someone somewhere is paying for it.
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Currently, more than 70 percent of the encounters Nigerians have with doctors and other healthcare providers are funded by out-of-pocket payment by the citizens. It is a limited, cruel reality, because many people suffer and even die daily because they cannot afford the healthcare they need.
An alternative formula for funding Free Health sustainably might have been a recourse to the formula Obafemi Awolowo used to fund ‘Free Education’ in the Western Region – taxation. This would have created a system like the National Health Service in the United Kingdom. However, Nigerians have a chronic aversion to paying tax, as the Inland Revenue Service may testify. To speak of adding an extra line of ‘taxation’ equivalent to the National Insurance contribution in the UK may be a bridge too far for any Nigerian government.
Health Insurance, not Taxation, and not an unfunded ‘Free Health’, is the way to give Universal Healthcare Coverage to all citizens of Nigeria.
When the National Health Insurance Law was introduced in 2004, there was optimism that accessible basic healthcare would soon be available in every village. The evolution has been somewhat less dramatic. There is one major reason for the failure. It was not compulsory.
There are African success stories in Health Insurance, such as Ghana and Egypt. Nigeria just has just joined that group, perhaps.
On paper, Basic Health Insurance is now mandatory for all Nigerian citizens.
There are nice-sounding elements to the law.
A portion of the Basic Healthcare Provision Fund, introduced since the National Health Act of 2014, will be put into a fund to provide services for ‘Vulnerable’ citizens who cannot pay their own subscription. Other funds from NGOs, corporate and donor organisations will be added to the pool. There will be an integrated database across the nation. Quality of care in every participating facility will be standardised. There is an unwritten assumption that private providers will be encouraged to build facilities in underserved populated areas, with guaranteed income based on capitation and fee for service.
The devil is in the detail.
The Authority is to promote, regulate and integrate all Health Insurance schemes in Nigeria, and to ensure that every Nigerian and every legal resident is compulsorily registered for Health Insurance. That will need political will of a level that has never been displayed by any Nigerian government.
While people may still obtain private ‘social’ health insurance, every citizen will be required to sign on to a government-mandated basic scheme. This is another touchy area that will take strong will to enforce.
The Authority shall advise the Minister of Health on how to define who is a ‘vulnerable’ citizen, and work with states to disburse subsidies for the healthcare of such persons.
The Authority shall ensure Quality healthcare is provided in all healthcare facilities.
The National Health Insurance Authority Act of 2022 is a bold step into the future for the people of Nigeria.
It should, as a first requirement, be taken off the table of political controversy, so that anybody aspiring to lead Nigeria is required to make an open and irrevocable commitment to it.
It can be done.
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