These first few days of a new government, ahead of our The Future of Health Conference on the 18th of June, are a good time to reflect on some of the opportunities that could bring about positive change in the health sector. At NHW, it is our view that, despite the euphoria that followed its establishment, the “National Health Insurance Scheme” has dismally failed to deliver for the Nigerian people. We decided to ask one of Nigeria’s true experts on health insurance to weigh in. Dr Chima Onoka, who writes for us this week, is a Consultant in Community Medicine and holds a PhD in Health Economics from the London School of Hygiene and Tropical Medicine. He has published seven peer reviewed articles on health insurance in Nigeria. Enjoy and learn.
We can change history by ensuring that everyone in the world has access to affordable, quality health care in a generation. Let’s make it happen.
(Kim Yong Jim, President, World Bank Group, 2013)
The past few years have seen the post 2015 global health agenda focus on the attainment of Universal Health Coverage (UHC). The primary institution with the responsibility for ensuring Nigeria attains UHC is the inaccurately named National Health Insurance Scheme (NHIS) (It is an implementing and regulatory institution not a programme as the name implies). Nigeria’s pathway towards achieving UHC should have been crafted, communicated and pursued with passion by the NHIS, the Federal Ministry of Health (FMOH), and the National Primary Health Care Development Agency. Yet 10 years after the first programme of the NHIS was launched, there is little to celebrate. This is despite enormous opportunities to expand coverage. A number of fundamental reasons account for the perplexing lack of direction (despite the abundance of activities) on the part of the key players involved in providing social health insurance for Nigerians.
First, there appears to be some confusion among the key players about what the NHIS represents and its purpose. The NHIS cannot be independent of the FMOH in practice (which it appears to be at the moment), and should not normally engage directly with states in a framework that does not involve the Federal Ministry of Health. It does not make sense for NHIS to attempt to independently engage with and accredit health care providers in states, without the participation of state ministries of health. It is inappropriate to create bureaucracies out of the NHIS and to attempt to turn it into a Ministry of Health (Insurance), as appears to be happening. Recently, funds available for coverage expansion have been used largely to expand the offices of the NHIS to every state. These same state offices were reduced to 6 regional offices about 8 years ago by NHIS managers at the time, so what has changed? What is the evidence backing the allocation of scarce funds to create these offices now with further staff recruitment? The primary purpose of the state offices appears to be an intention to create community based health insurance schemes (CHIS) in states. However, despite years of trying, there is no evidence that any CHIS established by NHIS has been sustained. These factors are still causing resistance to the NHIS and its philosophy of operation.
Secondly, in terms of governance, the managers of the NHIS have never really been accountable to the parent agency (the FMOH) other than at its beginning when the FMOH gave birth to the agency. The NHIS has also never really been properly governed because the governing council which has existed just for half of the NHIS’ lifetime is often made up of individuals that appear to have little interest in the organisation. Worse still, the NHIS has never been accountable to the Nigerian society. The simplest evidence is the failure to tell citizens how many people are actually covered at any point in time and how much it spends on them and on administering the process. This provision in the law establishing the NHIS has been consistently violated by its managers for the 10 years of the NHIS’ existence. Summarizing the coverage level in rounded figures of 3% and 4%, or 4 million and 5 million, as is often done by its leaders, fails to recognise the fact that the differences between these figures are ‘millions’ of actual “people”. Thirdly, most workshops and conferences organised by public agencies for coverage expansion appear to have lacked clear goals. For example, nothing concrete seems to have emerged from the famed UHC presidential summit of 2014 organised by the Federal Ministry of Health, suggesting that the purpose of the event was the event itself rather than any measurable outcomes. One would have expected a very well-publicized pathway to have been agreed at that meeting, with measurable steps that would have allowed short-term assessment a year after, but this was not the case. In the meantime, the NHIS has continued to engage with states, asking them to send in their premiums to the central pool of the NHIS. This has and will remain an exercise in futility simply because this strategy is inharmonious with Nigeria’s federal political structure. NHIS managers must wake up to the fact that it will be more productive to help states design bespoke programmes for their own contexts, rather than try and force them to contribute to a single national pool. While it is true that larger financial pools are more resilient, many countries with fairly successful social health insurance schemes are the size of single states in Nigeria.
We stand at a moment of exceptional possibility, when global health and development goals that long seemed unattainable have come within our reach. (Kim Yong Jim, President, World Bank Group, 2013)
Recent events in Nigeria have shown an increased engagement of citizens with the events that happen in the socio-political space in the country. People are more expressive, given the outgoing government’s disposition that allowed questions to be asked and criticisms to be made. There is also an incoming government that has provided some optimism through its campaign promises. These have combined to create optimism in various aspects of our national life, although health has been little mentioned.
Refocusing the NHIS and efforts towards UHC should start from clearly addressing the issues earlier mentioned. The governance and accountability structure already provided in law should be clarified and adhered to. Overall leadership for the UHC agenda should be provided by an informed Federal Ministry of Health, working with the State Ministries of Health and facilitating adoption through the National Council on Health. Leadership for UHC cannot be provided by the NHIS – it is wrong to do so when the health system is coordinated through the Federal Ministry of Health. The NHIS council ought to be filled with those who can ask the executives the right questions. The managers must demonstrate competence, innovation, capacity to use evidence, and a willingness to be accountable to everyone. The simplest place to start would be a simple number – how many Nigerians are currently covered?
Finally, professionals and the civil society need to wake up. The business of innovation for UHC strategies within the complex Nigerian health system is serious business. Additionally, the demand for accountability requires the skills to ask managers the right questions and the commitment to do so. In an environment where technocrats are often distracted by endless consultancies and civil society organisations are often content with just being invited to events and receiving recognition and some appreciation for their participation, little will be achieved.
Since both transformation and change imply motion, the important thing for serious managers of the NHIS and the parent Federal Ministry of Health to do will be to leverage on the opportunities provided within the polity to bring about motion in the right direction that will provide the revolution needed in and through the NHIS to progress towards Universal Health Coverage. The time to do so is now.