NHIA 2022 & THE REALITIES OF UHC

By Munachimso Ayo-Olagunju

Universal Health Coverage (UHC) as defined by the World Health Organization (WHO) means every citizen has access to the full range of quality health services they need, when and where they need them, without financial hardship. In 2015, the Nations of the world recommitted to achieving UHC by 2030 as one of the pillars of the Sustainable Development Goals (SDG).

However, the progress towards achieving this has been uneven across the board. In 2015 at least greater than half of the world’s population was yet to have access to UHC, with middle-andlow income countries bearing the brunt of this. 23 of the 27 countries ranked as low-income countries, which are the poorest in the world, belong to Africa while 21 of the 55 lower-middle-income countries equally belong to Africa (World Population Review, 2022), with Africa being at the epicentre of this underdevelopment, it’s very easy to see how close to home this hits.

Since its establishment in 1999 and operationalization in 2005, the National Health Insurance Scheme (NHIS) has been largely unsuccessful in meeting its aim of 40% Nationwide coverage by 2015, recording a measly 3% coverage which is largely comprised of Federal civil servants, despite provisions being made to target formal and informal sectors and the vulnerable.

The NHIS was internally and externally constrained by factors that greatly limited its capability to deliver on its mandate.

Experts and pundits alike argued in hindsight –which is always a perfect sight, that the scheme and program were bound for failure as it was even constrained from the getgo by the very act that established it. Hence, a brownfield-oriented approach was keenly required to address this, birthing the National Health Insurance Authority (NHIA) Act 2022. The NHIA Act is a landmark piece of legislation that was enacted in May 2022 by President Muhammed Buhari, to repeal the earlier National Health Insurance Scheme Act of 1991. This updated piece of legislation –the New Act is a major step in the right direction towards achieving UHC and was welcomed by all well-meaning Nigerians, industry players, key stakeholders and development partners as it seeks to address the shortcomings of its predecessor – the Old Act in the following regards;

Firstly, Health Insurance is now compulsory for all Nigerian residents! Everyone living in Nigeria is now mandated by law to procure health insurance.

Prior to the enactment of this Act, health insurance participation was voluntary. The Act went further to clearly define residents to include; all employers and employees in the public and private sectors with five staff and above, Informal sector employees, and All other residents in Nigeria. If a State setups a mandatory health insurance scheme, then residents in such states would be required to participate in the State’s health insurance scheme. However, nothing precludes residents of such states from participating in a complimentary private health insurance scheme.

The New Act introduces and stipulates the creation of vulnerable group funds, which would be used to cater to the subsidy and payment of health insurance coverage for the vulnerable in society, which are defined to include; children under 5, pregnant women, the aged, the physically and mentally challenged, the indigent and others as may be defined from time to time. The Vulnerable group funds are to be pooled from the Basic Health Care Provision Fund (BHCPF), health insurance levy, special intervention fund allocated by the government, interests from investments and others — grants, donations, gifts and contributions.

The Old Act used the NHIS as a vehicle to provide health insurance – to entitled insured persons and dependents. The New Act creates a regulatory body and umbrella for health insurance schemes and more clearly defines the roles of the body as;

Promote, regulate and integrate health insurance schemes; Improve and harness private sector participation in the provision of health care services; and

Do such other things that will assist the authority in achieving UHC

With the New Act, there’s a clear delineation of the roles and responsibilities of NHIA as a regulator, promoter and enabler of UHC, creating room for other State Health Insurance Schemes.

The New Act introduces ThirdParty Administrators (TPAs), which have been rightly defined to include; Health Maintenance Organizations (HMOs) and Mutual Health Associations (MHAs) while curbing the powers of the HMOs by removing fund management from them and residing it with the State Health Insurance Schemes (SHIS). The Old Act empowered HMOs to collect and implement contributions for premiums, including payment for services to healthcare providers, and investment of pooled funds not in use while the New Act curbs their powers to the collection of contributions for premiums on behalf of SHIS where they are employed to do so but must remit these pooled funds to the SHIS who will then manage, and or invest the funds through the NHIA. The New Act addresses a conflict of interest that existed in the Old Act, where the NHIS council included an HMO, which obstructed proper regulation and monitoring of HMOs, thus clipping the NHIS. The New Act doesn’t include representatives of HMOs as part of its governing council.

The New Act provides for contributions to a State Health Insurance Scheme fund payable by employers and employees in the formal sector, as well as individuals, families and groups within the informal sector, at a rate to be determined by each States council of Health Insurance Scheme. The three tiers of government, nongovernment and development partners are required to contribute to the vulnerable group. The Federal Government’s contribution to the vulnerable group is to be drawn from the BHCPF. The New Act also introduces penalties and punishment upon conviction for failure to; pay contributions on time, remit payments’ after deductions from an employee’s salary, pay healthcare providers after receiving services from them and provide care to an enrollee.

The objectives of the New Act are laudable. However, it would take a significant amount of sensitization at all levels and most importantly compliance monitoring, to achieve Eldorado. 10 months later and there has been no noticeable outcome in the health insurance landscape nor the execution of salient aspects of the NHIA. Suffice to say, it has been business as usual. As of the time of this article, even the governing council established in section 4 of the New Act is yet to be constituted and this is the governing council tasked with