Jocelyne Agbo still thinks about the death of little Aliyu. The questions keep recurring – “Did he die because his father didn’t do everything he was supposed to? Could I have done more? Could the government have done more to provide basic healthcare for him?”
She remembers visiting the Maikunkele community in Bosso local government, Niger State to meet smallholder farmers supported by her organization, Farm on Wheels. One of the farmers informed her that his little son had rashes on his body, and she advised him to quickly visit General Hospital Minna. She said he seemed reluctant, so she gave him the contact of a doctor at the hospital and told him to call her if encounters any difficulties. He apparently did not heed her advice. A few weeks later, she got a call that the little boy died. While she was not sure why the farmer did not go to the hospital, it is not too far-fetched that it may have been partly from the fear of what he would have to pay, as over 72% of Nigerians pay for healthcare out of pocket.
The government has agencies with specific responsibilities to help with governance. The National Health Insurance Scheme (NHIS) was set up to provide a financial safety-net for Nigerians in accessing healthcare so that the burden of healthcare expenditure does not become catastrophic.
Senate President Dr. Bukola Saraki described the recently passed Health Insurance Commission Bill as a massive achievement towards achieving Universal Health Coverage in Nigeria. While our lawmakers should be applauded for pushing through the Bill, implementation is where the rubber hits the road. Is the NHIS ready to effectively implement this Bill?
This year’s theme for World Health Day was “Universal Health Coverage: Everyone, Everywhere,” and activities took place globally to mark the day. But the prolonged crisis in an institution as strategic as NHIS, is one more wrench in the wheel, drastically slowing down Nigeria’s long walk to a viable, public sector-led, healthcare financing mechanism that can guarantee healthcare for all
Conversations around the NHIS controversies have largely centred around squabbles over who is right or wrong. Should the NHIS demand certificates of non-indebtedness from Health Management Organisations (HMOs)? As the battle of personalities raged, the debates have focused on political, ethnic, and religious agendas while neglecting to ask critical questions – questions around our commitment to health insurance, transparency in the NHIS, mandating private organisations with more than 15 staff members to provide health insurance and accountability of HMOs.
Professor Usman Yusuf, who was appointed as the Executive Secretary of the NHIS in August 2016, proceeded on administrative leave in November 2018 as directed by the Presidency to give time for an investigative inquiry. Since then, the agency became non-existent in the public discourse, until recently when recommendations of the panel were made public. Key recommendations of the inquiry include, dismissal of the executive secretary, dismissal of 13 senior officers in the agency and dissolution of the governing council.
As the controversy rages, the most important people are left out of the discourse – the patients who bear the brunt of an ineffective national health insurance scheme and are paying out of pocket to access healthcare. They are the ones losing hours of productivity that can contribute to our economic development. They are the ones losing their loved ones, their friends… their lives.
A staff at the Agency, who asked not to be named, told Nigeria Health Watch that nothing much has been happening over the past six months and this is leading to staff redundancy as they just come to the office and sit around without much to do. Ironic in an institution that holds such an important mandate for the wellbeing of Nigerians.
A call for the NHIS to take its rightful place
The NHIS is too important an agency to be redundant. The possibility of Nigeria attaining UHC is dependent heavily on its leadership. The Basic Healthcare Provision Fund (BHCPF) targets people in rural communities with half of the funds earmarked to provide a basic package of services in primary health centres through the NHIS. How can this happen if the agency is internally in disarray?
Last week, Minister of Health Professor Isaac Adewole announced that the Federal Government has disbursed N12.7bn to the Treasury Single Accounts (TSA) domiciled at the Central Bank of Nigeria for the parastatals meant to receive BHCPF funding. The largest chunk of those funds, N6.5bn, goes to the NHIS. It is critical that the NHIS is able to publicly lay out a strategy for how these funds are to be disbursed. Without a functioning NHIS, we lose the momentum to ensure the BHCPF gets to the people who need it most.
All the advocacy around epidemic preparedness, reduction of maternal and child mortality, polio eradication, HIV/AIDS, and access to quality healthcare can only be sustained with local resource mobilisation. The NHIS cannot afford to take the back seat but should actively work to put systems in place to effectively collect premiums from both formal and informal sectors. These premiums can go a long way in ensuring that Nigerians access basic health care services without depending on donors.
About 25 states have taken steps to set up and operationalise their mandatory state health insurance schemes. This is an important step towards providing universal healthcare for their citizens and edge Nigeria closer towards achieving UHC. But for this to happen, the NHIS needs to provide oversight, leadership and the guidance for smooth running.
A Mandate for all Nigerians
The NHIS’ mandate is to protect all Nigerians from paying for healthcare out of pocket. We need a strong, effective NHIS if Nigeria will take any steps towards UHC. We have evidence of what can happen if systems function effectively. One of such is the story of Christian (not real name) whose wife took ill and was admitted at the National Hospital Abuja in 2018. He said his wife’s health insurance as a federal government employee helped ease the financial burden and he was grateful for it. This health finance safety net is what every Nigerian should experience whether or not they work for the government.
Agbo says she is now considering getting health insurance for her farmers to ensure they don’t lose their lives or their children because they cannot pay for healthcare from their meagre resources. We must not let others like Aliyu’s father continue to live in fear of financial ruin from hospital bills. Little Aliyu’s death is a constant reminder that the NHIS is failing in its mandate and must be held accountable to do better.
One story readily comes to mind. I rotated the paediatric dentistry unit as a final year dental student sometimes last month. Two women brought their kids to the clinic for checkup, one was on NHIS, the other was not. The kid of the woman who was not on NHIS had to take five radiographs that cost about 4,000. The woman left the clinic that day coz she was not with cash and left her ATM at home, she promised to return the next day but never showed up till I left the posting about 3 weeks later.
In months to come, the boy’s adult teeth will decay and will have to be removed, this could have been prevented or at least better managed but the financing barrier won’t allow. On the contrary, her friend who was able to get the treatment her kids need. She’s just one of many examples. Government should increase the coverage of the scheme especially to people in the informal sector.