Four months after the new National Health Insurance Act (NHIA) was introduced to bring about a game-changing universal health coverage for all, a cloud of confusion about implementation still hangs over it.
States meant to play a key role in the trickle-down effect of the provision of the Act are confused about the demand for mandatory integration of the national insurance scheme with existing insurance plans run at state levels.
Commissioners for health in Lagos and Delta have called for an urgent review of the operational guidelines of the law, insisting that it was confusing and challenging to run two parallel schemes for the same set of enrollees.
In Lagos, for instance, the Basic Healthcare Provision Fund (BHCPF) that comes from the state through the NHIA provides a package that is different from the state’s package.
According to the provisions of the new Act, every individual resident in Nigeria must obtain health insurance, and all employers in public and private sectors with five staff members and above must enrol.
The NHIA’s formal sector programme requires that employees at the state level and those under organised private sector contribute five percent of their basic salary to the national scheme, while their employers contribute 10 percent.
The benefit package of the NHIA covers provisions including 90 percent of drug payments, access to emergency care, and 50 percent coverage of comprehensive health screening such as magnetic resonance imaging and computerised tomography scan.
The Lagos State Health Scheme law makes it mandatory for all residents of Lagos State in the public and private sector, including the unemployed, to enrol under the state health insurance policy.
While the state covers 75 percent of the annual family insurance premium for each public servant, workers contribute 25 percent over a stretch of 12 months.
Akin Abayomi, Lagos commissioner for health, said the challenge minimises the pooling of funds because there is a pool in the state insurance and another in BHCPF, creating an unhealthy co-mingling of funds.
“It is a challenge we must discuss with professor Sambo and see how we can address this double package. What I propose is that NHIA convenes a session where we can see whether all states will fit into the BHCPF bouquet or whether NHIA will just allow each state to run their bouquet and those funds just go into the state health insurance fund,” Abayomi said at a panel session convened by the Healthcare Federation of Nigeria at the Medic West Africa Conference in Lagos.
Also, under the state scheme, workers, including their spouses and a maximum of four children below 18 years, can access benefits at a facility of choice.
An annual premium of N6,000 is required for additional family members or dependents below 18, while those who are above 18 attract N8, 500.
But on the NHIA scheme, the premium on extra dependents costs N15, 000.
The clash of costs on both packages poses an equal challenge in Delta where a highly subsidised insurance scheme is already being run at a lower premium than the provision of the new Act.
Mordi Ononye, Delta state commissioner for health, said the state has conducted an actuarial report that found it is unrealistic for many to afford the premium under the new national insurance Act when the state premium is subsidised at N7,000.
The state government is now faced with a situation where it is forced to implement the same package with two different premiums, two different capitations, and two different fees for service for the same set of providers with the same monitoring and evaluation and quality management system, he said.
“There is a disparity in what we are implementing in a subsidised manner and what we are being told to implement. That has been a challenge but what we have tried to do is to continue to provide care despite the disparity,” the commissioner said.
Reacting, Muhammed Sambo, NHIA director-general, insisted that the national scheme is mandatory for all but refused to make commitments on the states’ call for a review of the operational guidelines.
He said the underpinning reason for social health insurance is to ensure cross-subsidisation as there are people who cannot afford to pay for services.