By Marcus Fatunmole
On May 19, President Muhammadu Buhari signed the National Health Insurance Authority Bill (2022) into law. The ICIR’s Marcus Fatunmole X-rays the law vis a vis the current state of health insurance coverage in the country while highlighting what could be contentious sections of the new law, written in 10 parts and 60 sections.
The overriding issue in the new National Health Insurance Authority (NHIA) law is that it makes health insurance compulsory for all Nigerians and legal residents in the country.
It also repealed the National Health Insurance Scheme’s Act Cap N42, 2004, thus transforming the hitherto National Health Insurance Scheme (NHIS) into National Health Insurance Authority.
Nevertheless, the repeal of the NHIS Act does not affect anything duly done by the NHIS, including the right, privilege, and liability accrued or incurred by the Scheme under the repealed law.
President Buhari said the new law brought hope to at least 83 million poor Nigerians who could not pay out-of-pocket for health.
The law provides that all indigent citizens enjoy free healthcare funded by tiers of governments in the country and their partners.
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To make the NHIA more functional, the Act creates a council to guide its operations.
Besides, the Act also provides for Third Party Administrators (TPAs) to act as health insurance promoters and ensure enrollees get satisfactory services.
They will work as links among the NHIA, enrollees and health maintenance organisations (HMOs) for effective service delivery.
Nigerian government failed to provide coverage for Nigerians through NHIS
Despite existing for nearly two decades, NHIS failed to enrol 10 per cent of Nigerians, according to multiple reports on health insurance in the country.
The Head of the Public Relations Unit of the NHIS (now NHIA), Emmanuel Ononokpono, could not provide the exact population of Nigerians enrolled on the Scheme when the ICIR reporter contacted him on Thursday June 16.
Poor health insurance coverage has denied many Nigerians access to hospitals, promoted self-medication, and resulted in preventable deaths of citizens and complications of ailments that hospitals could treat at low costs.
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The National Demography and Health Survey (NDHS 2018) put the average life expectancy of Nigerians at 54.7 years. The “untimely deaths” are linked to poor access to quality health services and other factors.
Nigeria has the world’s highest burden of malaria, sickle cell disease, Neglected Tropical Diseases (NTDs) and similar ailments.
The country ranks sixth globally in tuberculosis and second in HIV/AIDs.
Picture of a mosquito that causes malaria.
Report claims over 11 million Nigerians live with diabetes, and the Nigerian government said cancer kills as many as 72,000 people in the country yearly.
There are other deadly diseases such as cancer, diabetes, hypertension, measles, diarrhoea, and ulcer that health insurance could support sufferers to manage.
Because of lack of access to care, the country’s maternal mortality rate stands at 512 deaths per 100,000 live births, while the infant mortality rate is 67 deaths per 1,000 live births, according to the 2018 NDHS, the most recent health data currently in use in the country.
What the NHIS offered Nigerians
The NHIS provided enrollees in the formal sector programmes such as mobile health, group, individual and family social health insurance programme (GIFSHIP).
Its informal sector programmes were tertiary institution social health insurance, community-based social health insurance, and public-private partnership social health insurance.
Vulnerable groups under the Scheme include pregnant women, children under five, prison inmates, retirees and the aged.
Yet, not up to 10 per cent of the estimated 217 million Nigerians enrolled on the Scheme.
Despite other initiatives by the government to push the nation to achieve the Sustainable Development Goals (SDG) target 3.8, seeking Universal Health Coverage for all by 2030, Nigeria’s health insurance coverage did not cover as much grounds.
The National Health Act (2014) provides the Basic Health Care Provision Fund (BHCF), targeting to further increase Nigerians’ healthcare access, but for the COVID-19 pandemic that raised the government’s budget for health since 2022, the government’s allocation for the BHCF had hovered around N55 billion.
Inadequate funding for health leaves many public hospitals with obsolete and moribund equipment, while professionals working in them opt for greener pastures abroad.
Major features of the NHIA Act
Section three (b) of the NHIA Act mandates the NHIA to make health insurance mandatory for all Nigeria and legal residents.
Section three (c) of the Act directs the organisation to enforce the basic minimum package of health services for all Nigerians across all health insurance schemes operating within the country, including the federal, state, the federal capital territory and private health insurance schemes.
Section three (k) of the Act makes it a duty for the organisation to advocate for funds for the Basic Health Care Provision Fund, while paragraph J of the section requires that the NHIA provide and maintain information and communication technology (ICT) infrastructure and capability for the integration of all data on health schemes in the country, including the state health insurance schemes.
Managing the enrolment data in the country will make the government know the actual population of enrollees at any given time and provide the information on request to the public.
According to section 3 (m) of the Act, the institution will collaborate with partners and other agencies of government to educate people on health insurance.
Paragraph ‘n’ of section three requires the NHIA to devise a mechanism for ensuring that the basic healthcare needs of indigents are adequately met.
Gains of the law
All states will now establish a health insurance agency because the Act is mandatory for all Nigerians. Creating a state health insurance agency is a precondition for states to access funds from the Basic Health Care Provision Fund, where the federal government will provide money to meet the health insurance needs of the vulnerable.
This is captured in section 13(8) of the Act: “Every state which has established a state health insurance or contributory scheme and which complies with the requirement of this act shall be eligible to participate in the basic health care provision fund as established under the national health act and its guidelines.”
Such funds will complement whatever the states raise in their domains to provide health insurance for their people.
Section 13(6) of the Act empowers the states to provide health insurance cover. “Every state of the federation and the federal capital territory may, for the purpose of providing access to health services to its residents, establish and implement a state health insurance and contributory scheme, to cover all residents of the state and federal capital territory.”
Paragraph seven of section 13 also compels states and the FCT to establish an information and communication technology (ICT) infrastructure for data management, adding that such ICT infrastructure shall be integrated with and provide information in the requisite formate to the ICT infrastructure of the NHIA.
Similarly, sub-section seven of that part notes that “a state and the federal capital territory shall provide coverage for vulnerable persons under the state health insurance and contributory scheme through the basic health care provision fund and other sources and not require the payment of premiums for such coverage by vulnerable persons defined by this Act.”
Section 14(3) ensures the law denies nobody the opportunity of obtaining private health insurance, as long as the person participates in the government scheme.
But there is a caveat to that. The person cannot be categorized as indigent and is not eligible to receive free coverage as a vulnerable person under section 13(7).
The law prohibits anyone or firm not registered by the NHIA from providing health insurance services in the country.
Section 22(2) prescribes punishment by a fine of at least two million Naira and imprisonment of at least five years for offenders.
Sources of funds for the vulnerable group, as spelt out in section 26(1) are the basic health care provision fund, health insurance levy, money that may be allocated to the vulnerable group fund by the government, money that accrues to the vulnerable group fund from investments made by the Council, and grants, donations, gifts and any other voluntary contributions made to the vulnerable group fund.
It is the Council’s duty to determine the indigent persons that will benefit from the vulnerable group fund. This function of the Council is in Section 27(2).
Contributions to health insurance programmes under the new Act
Contributions to health insurance schemes in the country will be made through employers and employees in the formal sector, while individuals, groups and families shall pay in the informal sector, as contained in section 31(1) of the Act.
Section 31(2) explains that the three tiers of government in the country and development partners will pay for the vulnerable persons not covered by other schemes.
The federal government’s contribution will come from the basic health care provision fund.
Section 34(3) of the law prohibits health maintenance organizations from offering direct health care services to enrollees.
In section 40(1), the head of the NHIA will be known as the director-general and chief executive officer. The head of the NHIS was addressed as executive secretary and chief executive officer.
Arbitration of cases between NHIA, its agents and enrollees
Meanwhile, enrollees who are unsatisfied with the health insurance services they receive cannot sue their HMOs, hospitals, the NHIA, and its agents without first informing the NHIA in writing and waiting for one month before going to court.
Section 47(1) of the Act says: “No action shall lie against the authority, its agents or employees without prior notice in writing given one month before the institution of a legal action.”
Also, section 50(1) of the Act protects the staff of the NHIA from litigation by enrollees who could be victims of any fraudulent activities of the NHIA’s staff. “Subject to the provisions of this Act, the provisions of the Public Officers’ Protection Act shall apply in relation to any suit instituted against any officer or employee of the Authority.”
Sub-section two adds: “No suit shall be commenced against the authority, a member of the council or the director-general of the authority before the expiration of a period of one month, after written notice of intention to commence the suit shall have been served upon the authority by the intending plaintiff or his agent.”
Sub-section three continues that such notice shall clearly state the cause of action, particulars of the claims, name and place of abode of the intended plaintiff, and the relief being claimed by the intended plaintiff.
A major concern is that the intending plaintiff must state his address while making his complaint(s). Such action may endanger the life of the intending plaintiff.
More likely contentious issues in the Act
In addition to the procedures for suing the NHIA and its agents by aggrieved enrollees, other likely contentious issues in the Act are the composition of the Council’s membership, its functions, and the role(s) of the minister of health.
Section four spells out the membership of the governing Council. They are the chairman, one representative of the Federal Ministry of Health and Finance not below the rank of a director, the Nigeria Employers Consultative Association and the armed forces, and a representative of a civil society organization whose main activities focus on health.
Others are two representatives of organised labour, a representative of each geo-political zones in the country who will represent the states under the zones.
“Such representation is to be rotated between states every two years within the zone,” the Act says.
A patient engages in self-medication
The Council’s Director-General serves as the Council’s secretary, while members of the Council other than the director-general are part-time members.
The nation’s president appoints the council members on the recommendation of the health minister.
Two of what may be contentious functions of the Council in Section 5(d and g) are that the Council will regulate and supervise the various health insurance schemes established in the NHIA, and it will approve, license, regulate and supervise health maintenance organisations, mutual health associations and other institutions relating to the NHIA as may be determined.
Those functions may involve the Council in the day-to-day running of the NHIA.
Another sensitive part of the law is that the Minister could give the council directives “on matters of policy,” according to section 12.
This could cause friction between the Minister and the Council, as witnessed during the era of former Minister of Health Isaac Adewole, the NHIS Board and its former executive-secretary, Usman Yusuf, a professor.
Culled from International Centre for Investigative Reporting (ICIR)
