The enactment of the National Health Insurance Authority Act 2022 was welcomed by all well-meaning Nigerians as a step in the right direction on Nigeria’s road to Universal Health Coverage. The expectation was that such a beautiful law should not be left lying on the shelf but immediate, targeted and calculated steps would be taken to begin its implementation. This discourse reviews the key steps that have not been taken after the President, Major General Muhammadu Buhari(retd.), assented to the bill in May 2022. It points in the direction of positive action that is needed to kickstart the new regime of compulsory health insurance for all Nigerians.
The World Health Organisation’s definition of UHC means everyone has access to the health care services they require at the time and place they require them without financial hardship. UHC connotes a scenario where all persons and communities have access to the health services they need, at the necessary time and where they are needed without financial hardship. The services being referred to include: essential health services ranging from health promotion to prevention, treatment, rehabilitation and palliative care. Nigeria’s health indicators, from maternal and child health, access to water and sanitation facilities, life expectancy, etc., do not speak to Nigeria’s status as a leading African country. The country is so distant from the dream of UHC.
A critical necessity on the road to UHC is improvement in health financing to generate more resources per capita for health services. However, it is acknowledged that improvements in health financing do not depend solely on generating additional resources, but also on the efficient utilisation of available resources, and the effective and equitable deployment of resources within different population groups in the country, especially the underserved.
The first challenge is that the governing council established in Section 4 of the NHIA Act has not been constituted. The functions and powers of the council are so critical and fundamental to the realisation of the goals and objectives of the new regime established in the Act. Indeed, any new policy framework approved by the NHIA, when the council is not in place, would be of doubtful legal validity. However, in accordance with Section 58 of the Act, it is acknowledged that the repeal of the National Health Insurance Scheme Act will not affect the previous operation of the enactment or anything done or suffered under the enactment, any right, privilege, obligation or liability accrued or incurred under the enactment, etc.
The second issue is that a new regime of compulsory subscription to health insurance has been created for all by the Act. But this is the law in the books and not the law in the streets. It is yet to be implemented. Furthermore, the provision of the Act in this regard seems to be deficient within the context of the law being the command of the sovereign, to be disobeyed at the risk of sanction. Pray, what is the punishment for non-compliance? The Act is silent on enforcement and sanctions to be meted to defaulters. Such a big provision should not have been left to the regulations and guidelines of the governing council or authority.
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The third issue is that the regime of compulsory health insurance for all who do not fall into the category of vulnerable persons may be known only to health insurance professionals, workers and relevant civil society organisations. Indeed, the majority of the population, close to 98 per cent of the population, are unaware of this new regime. Therefore, enlightenment, sensitisation, awareness creation, education, etc., are imperative and relevant to achieve the goals of the new regime, and to increase health insurance penetration. But has this massive enlightenment and sensitisation started? It appears not.
The fourth issue is that the Vulnerable Group Fund established by Section 25 of the Act has not been fully activated. The Fund has many sources. The first is the resources accruing from the Basic Health Care Provision Fund, being not less than one per cent of the Consolidated Revenue Fund of the Federal Government, which apparently has been activated before the enactment of the Act. The second source of funding is the health insurance levy which has not been fixed or imposed. It is not clear, in view of the prevalent negative macroeconomic indicators, which sets of individuals, companies, or organisations that can afford to pay any extra levy. The third is the Special Intervention Fund to be allocated by the government and appropriated to the Fund. This is not yet in place, and it is surprising that the 2023 Appropriation Bill did not make a provision for this. Furthermore, the justification for the imposition of sin taxes, including sugar tax on carbonated drinks, increased duties on tobacco and alcoholic drinks, is linked to health- obesity and other non-communicable diseases such as diabetes, cardiovascular diseases, dental caries, liver disease, etc. However, the proceeds of these sin taxes are not targeted at health but goes to the bottomless pit of pooled funds that can be spent on anything including frivolous, inappropriate, wasteful and sometimes illegal expenditure.
Where is the database of vulnerable persons needed to activate the VGF? Vulnerable groups are defined to include children under five, pregnant women, the aged, physically and mentally challenged, and the indigent as may be defined from time to time. To be able to reach this group, the Authority and state Health Insurance Schemes need a census, a database of people who fall into this category, and which has to be regularly updated on a yearly or any appropriate interval basis. Pregnancy is a category that will last about nine months and so needs to be regularly updated in terms of persons who recently became pregnant, and pregnant women who have delivered. Also, the under five category needs to admit new entrants and phase out older members on a yearly basis. Is there a national or state register of the aged and mentally infirm persons? If the answer is positive, this register will be updated upon death or when a mentally infirm person regains his sanity. Is there a register of physically challenged Nigerians or people living with disability? The existing register used by the Humanitarian Affairs ministry for payment of cash transfers can only identify the indigent and not the other categories. And the validity of the Ministry’s register, in terms of containing only and all persons who are indigent, is doubtful.
The next steps should include the following. The Minister of Health should without delay make recommendations to the President, while the President should constitute and inaugurate the governing council. A massive enlightenment and sensitisation campaign on the new regime of compulsory health insurance should be launched by the authority in collaboration with state health insurance schemes. This should be followed by enforcement action after a couple of months. The Vulnerable Group Fund should be fully activated through the appropriation of a special intervention fund as well as a health insurance levy to be sourced from existing and new sin taxes channeled to the Fund. Finally, steps should be taken to kickstart a credible database of vulnerable persons, to be updated at regular intervals through collaboration with a multiplicity of government agencies and civil society. ,
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