We’ll bring every Nigerian under NHIS cover – Sambo
In the past seven years, the National Health Insurance Scheme (NHIS) has been in operation charting new courses to market a policy never known to Nigerians before. Today, after conquering the Federal Government labour pool, the Acting Executive Secretary of the project, Dr. Abdulrahman Sambo, in this interview with Daily Sun, revealed plans to stretch the project to include all states, local governments and private sector employees. He said, with time, the NHIS would adopt roles to cover even the self-employed and private citizens through community mobilization.
Would you rate NHIS as having done well since 2006 when it came on board?
The years have been very challenging but promising. The challenge is the type of mandate the scheme was given. It is a tough task to ensure universal health coverage by 2015 without the necessary resources to make this possible.
But it has been promising because we have made tremendous progress and we have the prospects of doing even better. The formal sector programme at the federal level has run fairly well, even though there were initial challenges of scepticism. At a point, the then Head of Service had to issue an ultimatum to civil servants to register with NHIS or forfeit their salaries.
Now, almost everyone at the federal service has registered with NHIS, except two groups of people those who are newly employed and those who wouldn’t want to join for one reason or the other. But otherwise the NHIS has covered all employees of the federal government. Some agencies that were not initially covered by the scheme have also independently approached the NHIS and registered their workers. Another indicator of acceptability is the number of extra dependants that we see on the growth. More enrolees now request for the inclusion of extra dependants. And if an individual is not satisfied with the services he or she gets, he or she wouldn’t pay extra money to cover extra relatives. We can say, so far so good, and though there have been challenges, we are overcoming them.
What has the agency achieved under your supervision?
We have attained some modest achievements. I will mention a few, not in any particular order. We have tried as much as possible to identify and address the challenges and difficulties in implementing the formal sector programme. These include beneficiaries wanting to add their dependants or to change providers. So we have simplified all that and individuals can go on-line to change their provider or add dependants. We have also cut wastages by removing from the register those who shouldn’t be there either on account of retirement or age. Also, we have finally commenced the collaboration with the International Finance Corporation on the e-NHIS, which has been on the drawing board since 2005. The project was earlier approved by the Federal Executive Council in 2006 but some issues came up and the approval was withdrawn in 2007. We then had to start afresh. The NHIS was to initially pay for 100 per cent for the implementation of the project, but IFC will now pay 60 per cent of the cost as an unconditional grant to us. The programme has started and Accenture is implementing it.
We have also handled the review of the operational guidelines and benefit package. We have reviewed the tariffs, another area of concern to healthcare providers for the cost of services for secondary and tertiary care. It was first introduced in 2005 and we have reviewed it and it is currently before the Ministry of Health for consideration and approval. We have started the process of consolidating the industry through the strengthening of Health Maintenance Organisations (HMOs). We have reviewed and got approval for the new requirement for accrediting HMOs and we are collaborating with PricewaterhouseCoopers to assist the scheme in strengthening our accreditation systems for the HMOs.
We have also modified the implementation of Community Based Social Health Insurance Programme (CBSHIP) and seen to its implementation in many states of the federation. At the same time, we have restarted the MDG/NHIS project within the past year. It is a project that actually won an award in the International Social Security Association as one of the pro-poor, cost-effective and efficient interventions.
The way it works is that government pays health insurance cover of children under the ages of five years, and pregnant women. Under that programme close to two million women and children were given cover. Now we have modified it by requiring states to pay counterpart funding, and many states are embracing it.
We have also recruited a fairly large number of staff within the past year to ensure the smooth implementation of our programmes. We have increased our collaboration with various stakeholders and also reached out to states, local governments and non-governmental organisations.
Health insurance is alien to many Nigerians and, insurance, generally, has negative acceptance. How are you dealing with these issues?
The major challenge is not just that most people are not used to the concept. What is the real problem is that they don’t understand why someone who paid for health insurance, cannot get a refund, if not used. Also, the traditional concept of illness and health in the Nigerian society is that if you prepare for ill health, it’s like you are wishing for it. So it took a little time to overcome that, but we are still having some little issues here and there.
Some people also believe that health insurance is not religiously permissible. We have also significantly overcome that and we have consulted quite a number of religious leaders. For example, when we started the formal sector programme in Bauchi State there was this initial resistance by some people who thought that health insurance was against the provisions of a particular religion. So we went out to identify the various religious leaders in the state and we got in touch with one who gave us a way to go about it.
I recall that after explaining the whole concept to him, he called one of his followers and asked him to cross the road and summon someone. The follower looked left and right before crossing the road. When he came back, the leader then said to his follower that he saw him looking left and right before crossing the road… and he said, yes. The religious leader said that is insurance. He said that it’s not that you believed that if you didn’t do that you would get knocked down by a vehicle, but you wanted to be sure, that was why you looked left and right before crossing. Now, that is insurance in a way. Since then we never had any challenge in the state.
In Kano State we got in touch with the Sharia Committee and discussed with them extensively, and they summoned some ulamas and did research and came up with a verdict that health insurance is not un-Islamic, and the state government readily accepted that. We also did the same in Sokoto that is considered the most traditional emirate in the northern part of the country. The CBSHIP and the MDG project seemed to be accepted in Sokoto State more than any other state.
So we have been able to break down prejudices and we have been able to reach out to people to get them to understand the concept and value of health insurance. The challenge has always been getting people to pay. For instance, an individual will tell you that he understands and agrees but he doesn’t have the money. It’s still a challenge, and that is why the scheme is finding it exceedingly difficult to penetrate the informal sector.
NMA said recently that not more than three per cent of Nigerians is covered by NHIS. A polling agency also said 79 per cent do not have any form of health insurance. Is coverage for all still achievable by 2015?
It is achievable but difficult. Achieving universal health coverage is extremely simple and easy. You need to identify those who should contribute and compel them to contribute; and you need to identify those who will contribute on behalf of those who can’t contribute. That’s all it takes to attain universal health coverage.
Compulsion and subsidy are two key things to attaining universal health coverage. Now who would you compel? It’s the employers of labour. Who should do that compulsion? Is it the federal government? To some extent, yes, because the FG can compel the private sector. But state governments are also employers of labour. Can the FG compel state governments to pay health insurance in a federal system? It is difficult, if not impossible.
So all we do is going round to sensitize the state governments, and we have achieved an appreciable level of success. We have also been promoting the establishment of a subsidy fund and, again, we have achieved an appreciable level of success on this. We will achieve significant level of coverage if all the state governments will commit themselves to universal health coverage; if those who can’t afford to pay will have somebody pay for them, and if the three tiers of government come together to establish a vulnerable group fund.
Are you saying it’s largely a funding issue?
Yes, largely so. Most countries earmarked some fund to finance universal health coverage. In Ghana, it is a portion of Value Added Tax and individual employee contributions in private and public sectors. We have identified the sources of funding in Nigeria and it has been factored into the proposed amendment of the NHIS Act. We also need to institute an operational mechanism to actualize universal health coverage. Funding is just one aspect; the mechanism to attain the cover is another thing. The question then is: can NHIS alone be able to do that? The answer is yes, but it is difficult. Should state governments have their own health insurance boards? Yes, this has been mooted. In countries like Nigeria, you may need to have state health insurance boards in order to attain universal health coverage. So there are various ways.
You need to go beyond the formal sector to attain universal coverage, so how are you engaging the informal sector?
We introduced two schemes to address those who work in the informal sector of the economy. One is the CBSHIP, which is owned by the community. The other one is the Voluntary Contributors’ Social Health Insurance Scheme (VCSHIS) for individuals who have the financial ability to pay N15,000 per annum. We are promoting these programmes though the uptake has been rather slow. We are also reviewing and looking into our strategy.
For the CBSHIP, we are quite impressed with the uptake by communities nationwide. We have flagged off in six communities. Also, there are many other communities that have commenced but haven’t been flagged off. Quite a large number of communities are signifying interest and we hope that by 2015 we will be operational in most communities that have organised themselves for the programme. We have seen states coming up with proposals to cover the entire state. They include Kwara, Lagos, Ogun, Ekiti, Niger, Ebonyi and many others that are looking at the state-based communities.
We also have one very interesting scheme in Katsina State. The Dutsin Ma local government area is subsidizing contributor for the poor. They identified the various district heads to get subsidy for those who cant pay.
So you have a number of people that the state is paying for and another number that is paying for themselves with the support of the local government. That is coming up very well and some politicians in that local government, especially members of the National Assembly and State assemblies, are also supporting or sponsoring some people. This is a concept that we are selling to other local governments so that the community and the local government, and those in positions of authority in the local government, can come together to finance community-based health insurance in their local government.
The VCSHIS is for individuals who can afford the premium of N15,000 per annum. He or she identifies HMO of his or her choice or approaches the NHIS. We use scratch cards so that one does not need to go to the office of the NHIS or any HMO to register. The scratch cards are supposed to be readily available as GSM recharge cards are. So you purchase a card for N15,000 and log unto the NHIS website and navigate to the VCSHIS page and follow the instructions. That is it. There is a two-month waiting period in order to create a pool.
For those who are not computer literate, the HMOs are out there to assist them in the registration. The NHIS is also decentralizing. We have offices in six states presently and, before the end of this quarter, we will have offices in almost 25 states of the federation and, before the end of the year, we will have offices in all states. The idea of those offices again is to assist those individuals in being able to register for the voluntary contributors’ programme and to also promote it at states and local government levels.
There will still be Nigerians who cannot afford the cost. Are there other funding mechanisms in place to cover the gap?
We have actually identified many other sources of funding. We have looked at sin tax; such as taxes on alcohol and cigarettes, and we have looked at tax on air travel. We have also looked at tax on telephone usage that we tagged one kobo per minute initiative. The idea is that for each minute that you talk, you are charged an additional kobo that will be collected centrally, and part of it will be remitted to NHIS in order to provide health insurance for the vulnerable. It’s a sort of tax on those making calls and not on the telecom companies. The concept has actually been forwarded to government by the NHIS. We consulted the Nigerian Communications Commission and forwarded a proposal. When we mentioned it to the President, he was quite enthusiastic about it.
When the Health Bill is signed, 1% of the consolidated revenue fund will be given to NHIS for the provision of healthcare to Nigerians. But it will certainly be inadequate as cover for all Nigerians. So we are thinking that we can use it mainly for the vulnerable group.
How will the planned NHIS Act amendment enhance adequate coverage?
Well, we have been pushing for the amendment of the NHIS Act since 2005. We have had discussions with the ministries of Health and Justice, and the National Assembly. The Senate and the House of Reps have initiated moves to amend the NHIS Act. The House of Reps has already concluded its part, while the Senate just concluded the public hearing.
The review aims to make health insurance compulsory; to create a Vulnerable Group Fund (VGF) and to identify sources of funding; to create other social health insurance pools, and to prescribe punishments for offences that could be committed towards the implementation of health insurance. So essentially, the review of the Act is to promote the attainment of universal health coverage.