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REVIEW ARTICLE
Year : 2022 | Volume
: 29
| Issue : 4 | Page : 281-287
The Nigeria national health insurance authority act and its implications towards achieving universal health coverage
Tope Michael Ipinnimo1, Kabir Adekunle Durowade2, Christiana Aderonke Afolayan1, Paul Oladapo Ajayi3, Tanimola Makanjuola Akande4
1 Department of Community Medicine, Federal Teaching Hospital, Ido-Ekiti, Nigeria
2 Department of Community Medicine, Federal Teaching Hospital, Ido-Ekiti; Department of Community Medicine, Afe Babalola University, Ado-Ekiti, Nigeria
3 Department of Community Medicine, Ekiti State University, Ado-Ekiti, Nigeria
4 Department of Epidemiology and Community Health, University of Ilorin, Ilorin, Nigeria
Correspondence Address:
Tope Michael Ipinnimo
Department of Community Medicine, Federal Teaching Hospital, Ido-Ekiti
Nigeria
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/npmj.npmj_216_22
The National Health Insurance Scheme (NHIS) faced several inherent and systemic drawbacks towards achieving universal health coverage for all Nigerians, and this has led to the signing of the new National Health Insurance Authority Act (NHIA), 2022. This article highlights the benefits of NHIA, discusses the possible challenges and the way forward in its implementation. A narrative review of past literature searched in PubMed, MEDLINE, African Journal Online, and Goggle was conducted. A total of 76 publications were initially retrieved and following data triangulation, 55 were finally used. The authors also included their experiences. The NHIA addressed some of the shortcomings of the previous NHIS, however, it would still face several challenges in its implementation such as low government funding priority to health, shortage of healthcare workers and poor healthcare coverage, as well as problems with enforcement as it mandates all Nigerians to enroll. These and other impending constraints must be surmounted and all stakeholders must be involved to ensure the Act accomplishes its aim.
Keywords: Health Insurance, National Health Insurance Authority, National Health Insurance Scheme, Nigeria, Universal health coverage
Universal health coverage (UHC) means that all people have access to the health services they need, when and where they need them, without financial hardship.[1],[2] Over the years, UHC has been a major pursuit of all the countries of the world more so as it has been included in the sustainable development goals of the United Nations, specifically goal 3, which is to ensure healthy lives and promote wellbeing for all at all ages.[1],[2],[3] The developing countries, of which Nigeria is one, have not been left out in this pursuit.
In 1999, Nigeria established the National Health Insurance Scheme (NHIS) under decree 35 of the 1999 constitution, however, the scheme did not become operational until about 6 years later on the 6 June, 2005 when it was officially launched and commencement of services to enrollees started in September of the same year.[4],[5] It operates as a tripartite public-private arrangement among three main stakeholder operators; the NHIS, the health maintenance organizations (HMOs) and the healthcare providers. The other stakeholders are the enrollees under the scheme. The target of the scheme was to achieve UHC for Nigerians by the year 2015 through improving the health of all Nigerians at an affordable cost.[4],[5],[6],[7],[8] As a country in the late expanding stage of population growth, Nigeria has a recent population of over 200 million with a high dependency ratio.[9] The populace would have been thought to be benefitting maximally from the NHIS following implementation for almost two decades while in fact, the opposite is the case as <5% of these millions of people are actual beneficiaries of the scheme[10],[11] and this has been a major drawback to the UHC.
The majority of Nigerians particularly the unemployed who are estimated to account for about 33% of the population[12] and the self-employed who accounted for 81.37% of the total employed[13] have not been adequately covered by the scheme with a coverage of just 3.4% recorded among artisans.[14] Likewise, dissatisfaction with services rendered to enrollees and problems with the remunerations of healthcare providers in the scheme to mention a few have been reported. This and other challenges brought about the advent of the National Health Insurance Authority (NHIA) Act that will not only allow the unemployed and informal sector to be catered for while reducing the financial burden incurred through health care but would also fast-track the accomplishment of the UHC. This article aims to review the NHIA act, highlight its benefits, and discuss the likely challenges as well as the way forward in its implementation.
MethodsThis research used a narrative review of publications and authors' experiences. A Review of published Original Research, Reviews Papers and Reports was done after identifying relevant literature using PubMed, MEDLINE, African Journal Online and Google as the search engines. The search techniques used were Key Words, Boolean operators and field searching. Search terms entered into the search engines were but not restricted to NHIA Nigeria, Social Health Insurance Nigeria, Healthcare Financing Nigeria and UHC Nigeria. Several other documents, policy papers and reports on health insurance in Nigeria published in English language by the World Health Organization (WHO), Federal Ministry of Health and Federal Government of Nigeria was also reviewed. Research articles with accessible full text, published in English language between 2012 and 2022 were included for review.
Articles that did not focus on benefits, challenges or recommendations of Health Insurance Schemes were excluded. A total of 76 publications were initially retrieved and following data triangulation, 55 were finally used. Data on benefits, challenges and relevant recommendations on health insurance schemes were extracted from the studies and triangulated. Information reported also included the experience of the authors from working with different aspects of the health system-private and public sectors, the WHO, participation in workshops, conferences as well as the press briefing on the NHIA Act by the Director General of NHIA and the health committees of the National Assembly of the Federal Republic of Nigeria.
Overview and Benefits of the National Health Insurance Authority ActIn an attempt to improve on the already existing health insurance scheme, the NHIA bill was signed on 19 May 2022, by President Muhammadu Buhari of the Federal Republic of Nigeria. This Act, which repeals the existing NHIS Act, has 10 parts which is divided into 60 sessions and several sub-sessions with the aim of promoting, regulating, and integrating Health Insurance Schemes, improving and harnessing private sector participation in healthcare service provision, and achieving UHC for all Nigerians.[15] As good as this sounds, will it be able to accomplish its objectives?
Foremost, unlike the previous law that was referred to as a 'scheme', this present Act is called an 'Authority' meaning that it exerts authority and regulates health insurance schemes in Nigeria. There is so much power vested in the NHIA ranging from the regulatory to supervisory as well as managerial.[16]
The Authority has the capacity to invest funds not in immediate use without tax on such investments. It also can insure private health insurance schemes using security deposits. Moreover, the Authority mandates participation in health insurance for every legal resident of Nigeria irrespective of employment status thereby mending one of the loopholes observed in the former NHIS law which was voluntary and beneficiaries were basically those employed in public and organized private institutions, especially the Federal Government civil servants and their dependents.[17] Making health insurance compulsory for all Nigerians will bridge inequality and further improve the Gini index of the country. Gini index, which is a direct measure of income and wealth inequality is currently 35.1% in Nigeria, this is higher than the 31.5% in Egypt, 29.6% in Guinea as well as 24.4% in Slovenia.[18] Equitable health financing method is a technique for lowering income disparity between and within demographic groups in a country.[19] In Nigeria, compulsory health insurance could help minimize wealth inequality from out-of-pocket (OOP) payment which constitute 70% of health expenditures within the country.[19]
Furthermore, a minimum package of health services that meet national health regulatory standards for all Nigerians across all health insurance schemes is enforced by the NHIA Act thereby ensuring equity in healthcare delivery for individuals enrolled in the scheme. Possible disparities in access to quality healthcare are further addressed in the Act by ensuring the integration of all the health insurance schemes that operate in Nigeria. Also, the Act has broadened its horizon of functionality by making itself available for research, statistics generation, and the use of information and communication technology infrastructures which will enable an up-to-date healthcare delivery to all enrollees targeted at achieving UHC.[15]
Worthy of note also are the measures that have been put in place by the NHIA Act to monitor the activities and different operations under it. This includes the 5-yearly reviews of its guidelines and the 3-yearly evaluation of the tariffs to be remitted to healthcare facilities.[15] This development, while putting the Act in check, will also help prevent losses on the side of the healthcare providers should there be inflation. In addition, the Act has a provision that has been made to receive feedback from enrollees as regards their experiences with healthcare providers, to report dissatisfaction with services and other suggestions to enable an effective and efficient healthcare delivery. This will help reduce and tackle abuse that enrollees may encounter from healthcare providers, HMOs and other third-party administrators as well as boost their sense of importance and belonging in the scheme.
Another leap made in the NHIA Act is the establishment of the Vulnerable Group Fund (VGF) as well as the implementation of the Basic Health Care Provision Fund (BHCPF). The Authority, in collaboration with the state health schemes, will be responsible for the implementation of the BHCPF. In the 17 States including the Federal Capital Territory[10] without a state health insurance scheme, implementation will be through a third-party administrator. Additionally, the Act made available revenue mobilization sources for the VGF which include: the BHCPF, health insurance levy, special funds allocated from the government, NHIA council investment, grants, donations as well as gifts. Unfortunately, the telecommunication tax which was included in the bill has been discarded.[16] The VGF is expected to target 83 million vulnerable and indigent Nigerians which is about 38% of the population based on the 2022 estimated population of Nigeria. It will be a significant increase from NHIS which was serving <5% of the population.[10],[11] This offers a ray of hope as regards the healthcare system in Nigeria and that the country might be a step closer to achieving UHC.
The management of funds has been placed in the jurisdiction of the state health insurance schemes and withdrawn from the HMOs thereby facilitating the prevention of funds misuse and embezzlement while improving accountability and enabling the delivery of quality healthcare through the appropriate use of funds.[15] Another notable part of the act is the increase in the health care packages offered to enrollees such as treatment for cancers and previously undiagnosed medical conditions, 1st h of care in an emergency unit, as well as first 3 h of stroke management thereby further reducing the financial burdens that come with them, especially the unforeseen occurrences like road traffic accidents. Lastly, ensuring a wide range of awareness of health insurance is addressed by the NHIA Act, which addresses one of the shortfalls of the NHIS.[20] This will further increase the uptake and participation in health insurance schemes.
Strengths, Weaknesses, Opportunities, Threats Analysis of the National Health Insurance Authority Act in the Attainment of Universal Health CoverageThere are three blocks or dimensions necessary for the attainment of UHC as listed in the strengths, weaknesses, opportunities, threats analysis in [Table 1]. These are equity in access (x1), quality healthcare services, (x2) and financial risk protection (x3). The attainment of UHC is dependent on the performance of a country on these three indices. There seems to be an existential perfect linear relationship (Y = mx), between UHC as the dependent variable, y, and the trio of (x1), (x2), and (x3) resulting in multiple linear relationship thus: Y = m1(x1) + m2(x2) + m3(x3).[21] Therefore, the summative positive linear interaction of these variables will have a greater impact on the achievement of UHC in Nigeria. In the NHIA Act, mandatory participation, implementation of BHCPF and VGF as well as awareness creation would aid equity in access, hence, positively impacting UHC. Nevertheless, low government priority to healthcare funding, supply challenge of poor healthcare coverage, demand related issues and high population growth would hinder equity in access and negatively affecting UHC. Consequently, ameliorating these negative factors will increase progress towards UHC. This is similarly applicable to quality healthcare services and financial risk protection.
Table 1: Strength, weakness, opportunities, threat analysis of the National Health Insurance Authority Act using the objectives of universal health coverage Potential Challenges in Implementation Not minding how fantastic and promising the NHIA Act appears, some obstacles are envisaged. Possible bottlenecks might be encountered in the implementation considering the past occurrences as regard to the state of Nigeria's healthcare system, the economy, and future projections.
The first challenge is funding, would it be possible to pull the Authority through considering the current economic state and government's low priority to healthcare funding in Nigeria? To procure a health insurance package for the 83 million vulnerable and indigent Nigerians at the current premium of ₦ 15,000 annually,[22] the country requires about ₦ 1.3 trillion ($ 3.1 billion) yearly, which is about twice the 2022 Nigeria Federal Ministry of Health budget.[23] Although the NHIA Act has a well-laid plan to pool resources and enhance risk pooling, nevertheless, these plans may not be feasible enough to mobilize this huge amount of money. Additionally, it has been revealed that a major setback to health insurance scheme in the country is poor financing.[24],[25],[26],[27] The proportion of the year 2022 budget allocated to healthcare in Nigeria is one of the lowest globally at 4.2% which is low against the 5% recommendation by the United Nation for developing countries and ridiculously low against the 15% that was recommended in the Abuja declaration of 2001.[28],[29],[30],[31] The Nigeria government's priority to healthcare has been consistently < 4% of the gross domestic product in the last decade, this has been marked by very high OOP payment from the citizen compared with Egypt and the United States.[18]
With such little support coming from the federal purse that should spearhead the Authority, the success of its implementation has been greatly narrowed and except the situation is rescued on time, the NHIA might be on its way down even before its implementation. The Federal government requires a huge financial healthcare investment increase from the current state to move the country to achieve UHC. Also, a past study revealed that achieving UHC is inversely associated with the proportion of a population living below the poverty line.[32] The enrollees are expected to pay a quota into the scheme, however, the majority of Nigerians may not be able to pay their deductions as about 4 in 10 are living below the poverty line.[33] Apart from this, retrieving payment from those in the informal sector may also prove difficult, all of which will affect the pool of funds needed for the scheme to pull through. There is also the issue of corruption in Nigeria and the NHIA fund may not be absolutely insulated or immune against this as it represents a microcosm of the larger Nigerian society.
Furthermore, the existing supply challenges of poor healthcare coverage in Nigeria[34] may serve as a hindrance to the accomplishment of reaching 83 million beneficiaries in 10 years. There is inequitable access to healthcare delivery as healthcare facilities available in the rural areas and some urban localities are grossly low in counts compared to the population of dwellers.[35] Besides, the ones available are barely functioning owing to a variety of reasons such as the lack of skilled and essential manpower,[36],[37] inadequate materials and infrastructure and low acceptability of the healthcare system by the population.[38]
Currently, Nigeria has 0.4 doctor, 1.5 nurses and 0.5 hospital bed to 1000 of her population which is relatively low when compared with Egypt and the United States.[18] These healthcare delivery indicators in Nigeria are much lower than the values recommended by the WHO[39] and based on the current rate of supply of about 5,000 doctors yearly, (based on the Medical and Dental Council of Nigeria register) it would take the country over a century to meet this target. This low ratio of healthcare workers to the population is to a greater extent affected by the mass emigration of the healthcare profession due to poor remuneration, poor working conditions among other reasons. The Nigerian Medical Association (NMA) noted in 2020 that 75,000 Nigerian doctors were registered with the Medical and Dental Council of Nigeria, but over 33,000 have left the country.[40] The problem of inadequate coverage is further compounded by conflict and serious insecurity from Boko Haram terrorism, kidnapping, banditry, communal as well as farmers-herders clashes.[41] Currently, Nigeria is ranked 143 on the 2022 global peace index out of 163 independent nations and territories.[42]
Additionally, despite the enrolment being mandatory and binding on all legal residents of the country, demand related issues remain a challenge, Nigerian government might not be able to fully enforce the Act on the people. Implementation and enforcement of laws binding on Nigerians by the government have always been a difficult task. Getting everyone to enroll to benefit from the health insurance may not be that easy, especially considering the unpleasant experiences of past enrollees[36],[37] by having to pay OOP for some investigations and medications, inability to access healthcare during industrial disharmony, inability to access some specialized care as well as dissatisfaction in the quality of care experienced by enrollees.[43] These factors are disincentives to the populace and might affect enrollment.
Also, implementing a mandatory health insurance scheme for all Nigerians will require a lot of resources to carry out its activities such as awareness creation and education, enrollment of participants, licensing, supervision, and monitoring of healthcare providers, HMOs, as well as providing quality of healthcare services. These activities would require quite a huge number of human, material and other resources which are currently not available to deal with that volume of enrollees. The implementation of the NHIS which reportedly catered for <5% of Nigerians encountered such a bottleneck, how much more is the NHIA that is proposed to serve over seven times that population. Over and above that, the population growth rate in Nigeria is 2.5%, which is very high compared with the global average of 0.9%.[18] This shows that the population of the country is expanding rapidly and this may impact the coverage of health insurance. Also, a previous study revealed that achieving UHC has a strong direct association with a low fertility rate.[32] For example, the United State with a fertility rate of 0.1 has a higher UHC service coverage index of 83% compared with Nigeria which has a high fertility rate of 5.2 and a UHC service coverage index of 44%.[18] If the present population growth rate and fertility trend continue, Nigeria will rank third most populous country globally by 2050 and subsequently second by 2100 with a population of about 400 million and a billion people respectively.[44],[45] Available data also showed that an average of 5 million people are added to the country every year[18] and enrolling extra 5 million people yearly in addition to meeting up with the current target may require much more planning and resources. The rate of enrolment must meet up and surpass that population growth in order to achieve UHC.
The Act also plans to incorporate and ensure the proper functioning of the private healthcare providers who account for a significant proportion of the Nigerian health system.[46] However, there may be some challenges in getting these players on board and failure to get them may constitute a setback to a successful implementation of the Act.[47] One of the issues with the private health facilities is the possibility of having only a few of them pass the accreditation process to be on the scheme. A national study revealed that less than two-thirds of private health facilities have been accredited by the NHIS and almost half of these have <100 enrollees.[48] Another concern with this group is that they may have a lower willingness to participate because of the unpleasant experiences that have been encountered by those who ventured into the previous scheme, particularly in the aspect of receiving payments from HMOs. More than half (57.2%) of the private healthcare providers expressed regrets in accepting the scheme in a study done in Lagos State, Nigeria.[24] Thus, getting them to work with the insurance scheme through NHIA may require a lot more effort than envisaged in the Act.
Lastly, there may be challenges with ensuring equitable patronage of all levels of healthcare in Nigeria, considering the state of the health system with the primary and secondary levels of the healthcare system barely functioning optimally in most states.[49] This would also affect accrediting these health facilities. And even if they scale through the accreditation process, enrollees may, however, not be convinced to go to them to access healthcare, given that some needed healthcare services may not be available. This and other challenges must be addressed to achieve the aim of the NHIA.
RecommendationsThe NHIA Act has the potential to transform the Nigeria's health system. However, for this to occur, the federal government health spending must improve from the current value to at least 15% of the budget in line with the 2001 Abuja declaration. Furthermore, the NHIA Governing Council and each of the state health insurance schemes must put in place a workable, transparent, and accountable plan to mobilize adequate revenue to ensure the system is adequately funded and kept running. Revenue generation methods may include investment by the Governing Council on behalf of the system as this is backed by the Act, getting committed voluntary donors that will contribute on regular basis, and by creating platform where people will be financial shareholders in the system. The Governing Council and Director General of the Authority need to create a standard workable means of retrieving deductions from enrollees, especially those in the informal sector even if it means using non-monetary premium contribution methods such as farm produce and in-kind payment with a convenient frequency of payment[50] while ensuring that the existing means of funding are reinforced for better mobilization of funds to ensure adequate fund is pooled for the scheme.
Secondly, the renovation and appropriate staffing of the abandoned and dilapidated health facilities should be ensured by the state governments in collaboration with the National Primary Healthcare Development Agency to allow adequate coverage of the unreached areas in the country in such a way that healthcare can be made accessible to all. Benefits and bonuses should be made available for healthcare workers and other human resources that are willing to work in remote and rural areas as well as ensuring the provision of basic infrastructural facilities in these areas to enhance the pulling of skilled workers.[51] To meet the demand for health workforce, the federal government must work to retain healthcare professionals working within the country by providing the pull factors such as job opportunities and good working conditions while improving upon the push factors such as poor emolument and insecurity.[52] The supply of health professionals may be increased by collaboration between the Federal Ministry of Health and Federal Ministry of Education to create and accredit more medical schools and training colleges, give educational subsidies and scholarship to those in training, as well as task shifting and task sharing among professionals.
Furthermore, private healthcare providers' participation could be harnessed through engagement with appropriate stakeholders including collaboration with the Association of General and Private Medical Practitioners of Nigeria and the NMA. Efforts should not be spared by the NHIA in advocating the bye-in of private healthcare providers to ensure their unreserved participation and in correcting the bottlenecks that were encountered with their capitation and other payments in the previous scheme to encourage their full cooperation in the system.[53]
The NHIA Governing Council and Director General of the Authority must be accountable to all the stakeholders (enrollee, private and public healthcare providers, HMOs and other third-party administrators) to build confidence in the scheme. They must conduct regular performance appraisals and apply immediate corrective measures to erring sections, implement and make sure the feedback pathway works and feedback is received from participants on their satisfaction and perception of the system and its activities at all levels.
The federal government must adopt and implement policies that will reduce the current population growth. Population control measures such as promoting and expanding access to family planning, female education and raising the status of women, as well as incorporate population growth and family planning into secondary school and university curriculum could be adopted and implemented. To ensure every citizen participates in health insurance, widespread continuous publicity of the NHIA is necessary[54],[55],[56] by the National Orientation Agency, media houses, civil society organizations and the Authority itself. Public enlightenment must focus on the benefits offered by NHIA and showcase these as the incentive for enrollment, as people tend to partake in programs with incentives.[57]
ConclusionIn conclusion, the signing of the NHIA Act was a welcoming and assuring development for the Nigerian health system. The Act addressed some of the drawbacks of the previous NHIS by making it mandatory for all Nigerians and making provisions for VGF to cover the indigent and vulnerable individuals. Although the Act appears promising in accomplishing the UHC, some constraints are expected. These challenges include low government funding priority to health, shortage of healthcare workers and poor healthcare coverage compounded by insecurity, the problem of full enforcement and reduced likelihood of getting everyone to participate. Others are unavailability of resources for full-scale implementation, problems meeting up with the rapidly expanding population, poor commitment of private healthcare providers and inequitable patronage. These problems must be overcome and all hands must be on deck by all the participants to ensure the Act accomplishes its objectives.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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