Re-defining Nigeria’s health insurance system

Invariably, health insurance remains a veritable tool for achieving Universal Health Coverage (UHC) in Nigeria. It is the platform that offers opportunities to the poor and the vulnerable to secure access to healthcare without financial burden. In a country with a majority of the poor, such an arrangement becomes imperative if UHC is to be attained. No wonder all eyes are on NHIS in the nation’s quest for the achievement of universal healthcare coverage for all Nigerians.

The benefits of this can be observed from two perspectives, including the economic and social welfare advantages for the country whereby a healthy populace will be highly productive and thus create wealth that becomes the basis of improved social welfare conditions in the country. Conscious of these benefits, in addition to the requirement to meet the global agenda set by WHO for nations of the world to attain UHC as a factor for improving human conditions and capital around the world, NHIS was faced with the search for the enduring formula to achieve this feat. The result is the development of the conceptual framework called Health Insurance Under One Roof (HIUOR), which is a coordination mechanism for the effective management of the activities of all stakeholders in the implementation of health insurance in Nigeria. However, efforts of the National Health Insurance Scheme (NHIS) to attain UHC come 2030, especially by a presidential mandate, have been impeded by various economic, legal, operational, structural and institutional bottlenecks over the years.

Realizing the overwhelming task of expanding coverage of affordable, effective and qualitative healthcare to all Nigerians, and the avoidance of a retrogressive healthcare funding mechanism, and also, as part of its rebranding agenda and new result-oriented ethics, the National Health Insurance Scheme (NHIS) has unveiled a new initiative called Health Insurance Under One Roof (HIUOR), which is expected to accelerate the Universal Health Coverage drive. According to the Executive Secretary, NHIS, Professor Mohammed Nasir Sambo, health insurance is “consistent with the vision of President Muhammadu Buhari to rapidly unlock the potentials of Nigeria’s human capital towards improved socio-economic status of all Nigerians in the shortest possible time”.

He further stated that the “pressing urgency imposes on us all, the task to think outside the box and generate concepts and processes that will accelerate health insurance coverage in the country”. Health insurance under one roof is one of such concepts expected to speedily rehabilitate the health insurance processes nationwide, resulting in incremental growth of coverage in the country through coordination, integration and harmonization of the entire health insurance space in Nigeria. In the quest for UHC attainment, the first process the NHIS embarked upon was decentralising health insurance to ensure grassroots effectiveness, enabling every state have its own State Health Insurance Agencies (SSHIAs) that reflects the peculiarity of each state, and designed to maintain high standards in healthcare delivery system.

However, this has been uncoordinated and poorly regulated without a focus on UHC. To enhance the conceptual framework of HIUOR developed by the current leadership of NHIS, the Scheme organised a 3-day strategic retreat in collaboration with all state health insurance schemes in the 36 states and FCT, organised labour and key development partners, to input their ideas into the HIUOR framework and develop a concrete practicable concept acceptable to all. Expected outcomes from the HIUOR retreat include: To develop a framework for coordination and regulation of social health insurance towards the attainment of Universal Health Coverage in Nigeria To define the roles, responsibilities and operational modalities for the implementation of a decentralized health insurance system in Nigeria.

To develop a framework that will facilitate the smooth operations of all stakeholders in the health insurance eco-system.

To develop a framework for harnessing innovative financing opportunities for effective risk equalization.

To develop an effective peer review and joint learning platform for the smooth operation of social health insurance in Nigeria.

The rationale behind the inclusiveness of stakeholders and SSHIAs in fine tuning the HIUOR concept stems from the 3-point rebranding agenda of the new NHIS administration, which are:
1.Value Reorientation aimed at engendering a credible organisation committed to integrity and efficiency in the pursuance of our mandate 2.Transparency and Accountability, which entails openness and mutual inclusivity in the conduct of our operations and  business processes, and 3. Accelerating the attainment of Universal Health Coverage in Nigeria. Prof. Sambo explained that “at the inception of the current administration in NHIS, we declared a 3-Point Rebranding Agenda, following a critical analysis of the crisis that rocked the Scheme, with reference also to its many years of arrested development and the many causative factors”. He further stated that “we have consistently emphasised our commitment to prioritising stakeholder engagement in our activities. The reason for this is to engender common purpose and direction, synergy and team spirit, as well as to enrich decision making. This is because working together, we can do more and do better”.

At the retreat, the Chairman of the Forum of Chief Executives of State Social Health Insurance Agencies, Dr. Adeniyi Oginni noted their satisfaction with their involvement to fine-tune the HIUOR concept, stating that “it allows the adoption of ideas from states into the finalisation of the concept of HIUOR”. Also speaking at the retreat, Dr. Emmanuel Meribole, the Director of Health Planning Research and Statistics at the Federal Ministry of Health, representing the Honourable Minister of Health, Dr. Osagie Ehanire, stated, “we must double our efforts to ensure that quality healthcare is given to all Nigerians and implement mandatory health insurance deliverables”. The Minister’s representative admonished the CEOs of SSHIAs to “take your duties under HIUOR as a very serious one”, adding that “reports will be given to Mr. President on a quarterly basis”.

The new HIUOR conceptual framework is reinforced by five significant pillars; political economy, legal and institutional frameworks, New technology which includes Information, Education and Communication (IEC), innovative financing and sustainable investment (Equity fund and BHCPF), and strategic stakeholder engagement and partnerships (local and international). Political will and support is a critical component for the recalibration of health insurance under the HIUOR framework, as it engenders the required investment for health insurance coverage, while there is an urgent need for the modification of the current legal and institutional frameworks for health insurance in Nigeria, bringing it in line with global best practices, if the objectives of HIUOR are to be achieved. New Technology, which flows hand in hand with Information, Education and Communication activities, is essential in ensuring increased awareness and coverage in an increasingly urbane and informed population. UHC will be unattainable without inventive creation of additional funding and investment streams.

In order to sustain health insurance operations, create a safety net for the poor and less privileged, and mobilize the additional finances envisaged under the framework. The final pillar of the HIUOR framework, strategic stakeholder engagement and partnership, aims to ensure collaboration and affiliation with relevant local and international partners towards receiving requisite technical, financial and institutional support for the success of health insurance. The HIUOR framework notably highlights NHIS enrolees as the paramount foundation of the structure, alongside their benefit packages and UHC plans, the HealthCare Providers (HCPs) and Health Maintenance Organisations (HMOs).

NHIS, in this framework will strategically coordinate the health insurance policies and plans in a bid to guide and strengthen the SSHIAs; Regulate health insurance activities nationwide through monitoring, supervision and evaluation of healthcare processes; aggregate ICT and legal frameworks; and ensure risk equalization.

However, the SSHIAs are expected to regulate and implement necessary processes at the state level. The development of the new framework, which is expected to be the new benchmark for health insurance in Nigeria, relied on an all-inclusive engagement by the public and private sector players in the health insurance system, and the communique released post-retreat had input from the CEOs of the SSHIAs and the key development partners.

Resolutions from the communique are:
1.Health Insurance Under One Roof is a veritable concept for the coordination and harmonization of Health Insurance in Nigeria for which the commitment of all stakeholders is imperative.

2.A conceptual framework for Health Insurance Under One Roof be adopted by all stakeholders.

3.A Technical Committee be set up to drive the process for production and adoption of a policy document with clear monitoring and evaluation strategy.

4.NHIS and SSHIS shall ensure timely implementation of the adopted policy document through necessary administrative and technical actions that may be required.

5.The National Health Insurance Scheme and other stakeholders should engage with the National Assembly to fast track the review of the NHIS Act with a view to making Health insurance mandatory, accelerate the passage and assent to law.

6. NHIS shall facilitate the integration of the various existing ICT platforms by operators to allow for seamless interoperability and easy implementation of health insurance in Nigeria

7.The NHIS shall institutionalize a functional Health Insurance Information Management System (HIIMIS) to ensure generation of evidence-based information for effective decision making at all levels.

8. Political leadership at the different levels of Government should demonstrate more commitment to Health at the level of inclusive policies and funding to achieve Universal Health Coverage.

9.NHIS and SSHIS shall adopt innovative financing mechanisms to mobilize additional resources and catalyse access to care and quality improvement towards the attainment of UHC in the shortest time possible.

10. All Nigerians and legal residents shall subscribe to the National Health Insurance Scheme or the State Social Health Insurance (Contributory) Schemes for the statutory basic package for effective pooling to enhance the achievement of UHC.

11. All Ministries, Departments and Agencies (MDAs) and other personnel of Federal, State and LGA shall enrol as a matter of urgency in the available Social Health Insurance Schemes.

12.All States that are yet to establish their Social Health Insurance (Contributory) Agencies and implement the Scheme shall do so as a matter of deliberate Policy.

13.NHIS, SSHIS and Development Partners shall institutionalize strategic quarterly stakeholder engagement and coordination meetings to ensure the effectiveness of Health Insurance Under One Roof.

14.NHIS in collaboration with Partners shall facilitate regular capacity building activities for SSHIS.

15. Appropriate communication strategies and tools should be developed and deployed to support the implementation of Health insurance under one roof.

16.The NHIS Gateway of the BHCPF should be used as equity fund directly into SSHIS to ensure equitable benefit for all especially the vulnerable.

17. National Health Insurance Scheme, with the support of Partners will produce and disseminate guidelines for health insurance implementation while ensuring adequate engagement from all stakeholders in the process.

In his message to the retreat, the Governor of Nasarawa State, Engr. Abdullahi Sule, and host of HIUOR Retreat, represented by the Commissioner for Health of the State, Pharmacist Ahmed Yahaya Baba declared that the state is committed to ensuring qualitative healthcare deliverables for its people, as the governor believes that “when the health of a state is insured, the future of the people will also be insured”. Meanwhile to fast track the implementation of HIUOR, the Management of NHIS has inaugurated a Technical Working Group (TWG) to produce the policy document for the concept. To serve as a guide, the Terms of Reference for the TWG include studying and analysing the adopted Health Insurance Under One Roof framework, with particular reference to the operationalization of every element of the communique arising from the retreat. To accentuate the significance of the working group and its charge, it is being chaired by the NHIS boss, with other members drawn from the Federal Ministry of Health, the Forum of Chief Executives of State Social Health Insurance Agencies (SSHIAs), Development Partners (represented by WHO), and the Civil Society Organisations. The Health Insurance Under One Roof is an initiative by the NHIS Boss, Professor Mohammed Nasir Sambo, developed to reduce the fragmentation in the operations of health insurance in Nigeria, by bringing all state health insurance agencies and other players together on a single platform.

Njideka is an assistant manager, Media Division, NHIS.