POLICY OF NATIONAL HEALTH INSURANCE SCHEME IN NIGERIA; EFFECT, PROBLEMS AND PROSPECTS (A STUDY OF MINISTRY OF EDUCATION ANAMBRA STATE)

ABSTRACT: This study examined National Health insurance scheme operations in Ministry of Education Anambra State. During the course of this study, relevant literature were reviewed, a sample size of 200 was gotten from the population using simple random sampling. Data was generated using five scaled structured questionnaire ranging from strongly agree to strongly disagree. Hypotheses were formulated and tested using the Chi Square analysis. Findings from the study reveal that there is a low level of awareness of the National Health insurance scheme programme in Ministry of Education Anambra State; there is a low level of accessibility and coverage of National Health insurance scheme programme in Ministry of Education Anambra State. Findings from the study also revealed that government have made no effort towards funding health care centres under National Health insurance scheme programme. Based on the findings, it was recommended that National Health insurance scheme should embark on massive advertisement and enlightenment campaign in other to bring to the notice of the people especially rural dwellers the existence of the scheme. This campaign should also be geared at instructing people on how the programme works, why it was established and what they stand to gain from being enrolled. Also, the government should also make a legislation that makes it compulsory for every state to be enrolled in the scheme. This will help state government workers to enjoy the benefits that flow from the National Health Insurance Scheme.

AN OVERVIEW OF POLICY OF NATIONAL HEALTH INSURANCE SCHEME IN NIGERIA; EFFECT, PROBLEMS AND PROSPECTS (A STUDY OF MINISTRY OF EDUCATION ANAMBRA STATE)

CHAPTER ONE

• Introduction
• •  Background to the Study

The challenges of providing accessible and affordable health care services in developing countries including Nigeria have continually been of concern to international agencies (WHO 2007). Social Health Insurance (SHI) is a health sector financing alternative to the cash-and-carry system that had been in operation in the past. The health burden in countries world over has continued to escalate. The most vulnerable are the poor while the wealthy are the healthier. This means that whereas the economic statuses of the poor could not accommodate their health needs, the wealthy seem to spend less (in percentage terms) of their income on healthcare needs. One of the basic principles of the World Health Organization (WHO) in the 1946 constitution states that “the enjoyment of the highest attainable standard of healthcare is one of the fundamental rights of every human being without distinction of race, political belief, economic or social condition” (WHO, 2006). This declaration brought to the fore one of the greatest challenges of governance in this century. It puts on governments the burden of creating and maintaining a healthcare system that will ensure complete physical, mental and social well-being of their peoples. The responsibility of establishing, financing and sustaining a high profile health system that can facilitate the accomplishment of this noble obligation by governments has never come easy anywhere in the world. These challenges coupled with the fact that national growth is a function of the wellness of the citizens, led Emperor Otto Vo Bismark of Germany to enact a mandatory law on “sickness funds” in the year 1883, (Awosika, 2005). This “sickness funds” is what has metamorphosed into what is called Social Health Insurance (SHI) in almost all the countries of the world today.

Social Health Insurance began in Germany in 1883 by requiring that workers be covered by the sickness funds maintained by labour unions and various trades. Japan enacted her own insurance law in 1922 (Ijeomah, 2005). In Britain, the National Health Service Act of 1946 which went into effect in 1948 provided a socialized health care system for all citizens because “citizens were deemed to have a right to free health care regardless of income”, (Microsoft Encarta, 2006). By 1970 s, nearly all urban Chinese population and 85% of ruralites had been covered by one form of health insurance or the other, according to World Bank Report, (Zhu et al, 2008). The National Health Insurance Scheme was implemented in Taiwan, in 1995, (Lee et al, 2004) and in 1996, the Government of Tanzania initiated the Community Health Insurance Scheme with the aim of improving access to health care, (Jutting , 2004). Subsequently, the National Health Insurance Scheme was launched in Nigeria on October 15, 1997 and was passed into law with the promulgation of decree no.35 of 1999.The scheme however under the leadership of chief Olusegun Obasanjo was reinvented with legislative modification made in 2005. Its broad objective was to ensure that every Nigerian has access to good health care service at an affordable cost. The scheme was established to cover those in formal sector (civil service), urban-self-employed, tertiary students, armed forces, some pregnant women, children and such population as the disabled and prison inmates (Awosika, 2005). The actual promulgation of the enabling legislation, Degree 35 of 1999 became the first major government commitment that facilitated the schemes eventual take off, six years later.

The objectives of the scheme ordinarily will appear easily achievable to many until they are viewed in the light of Nigeria’s health indices. According to World Development report (2005),Nigeria’s population as at 2003 was 135.6 million. Annual growth rate was 2.1%, life expectancy at birth was 45.3, infant mortality was 100 per a thousand live births and under -5 mortality per a 1000 live births was 108 deaths. With respect to disease control, access to improved water was 60%, improved sanitation 30% success rate of treated Tuberculosis (registered cases) was 70 while directly observed therapy short-course (DOTS) detection rate per registered cases was 18%. In reproductive health, fertility rate stood at 5.6%, adolescent fertility (per 1000) was 122, and pregnancy related mortality rate (per 10,000) was 800 deaths. 13% of women (aged 15-45) made use of contraceptives. While 35% of deliveries were attended to by skilled staff, 17% were not. Risk factors and future challenges showed Tuberculosis prevalence, 293 per every 100,000, HIV prevalence between ages 15-49 was 5.4% while incidence of diabetes (within ages 20-79) was 0.4%. In a country with a population of one hundred and thirty-five million citizens, financing the health sector could no longer be handled from dwindling Government resources alone. This need for equitable distribution of healthcare cost led to the establishment of NHIS in Nigeria in the year 2005.

Unfortunately, even with the wide range of coverage expected of the scheme, it has only succeeded in enrolling only 6million out of 160million Nigerians (Adebayo: 2013). Most of the enrolees are federal civil servants. Further, less than one thousand persons are registered under the community based social health insurance programme in Anambra state (Agu: 2014).

According to the World Health Organization (WHO) in 2015, Nigeria ranked 197^th out of 200 nations; life expectancy was put at 48years for male and 50year female while health life expectancy (HALE) for both sexes was put at 42years. Nigeria accounts for 10% of global maternity mortality with 59000 women dying annually from pregnancy and child birth; only 39% are delivered by skilled health practitioners.

In the light of this difficulties faced by this all important scheme, Rural Community Based Social Health Insurance Scheme was launched in 2010 as part of the activities of NHIS to create awareness, register citizens into the scheme and issue identity cards.

However, with pragmatic efforts geared towards achieving the no less than 30 percent of Nigeria’s population target giving by Ex President Goodluck Jonathan, the Universal Health Coverage of the World Health Organization and the first of its kind National Mobile Health Insurance Programme there seems to be light at the end of the tunnel for revamping the already collapsing National Health insurance scheme of Nigeria. But this can only be achieved with vigorous management effort towards creating the needed awareness, efficient management of available resources and subsequently launching of every Nigerian into this quintessential scheme.

• Statement of the Problem

The National Health Insurance Scheme in Nigeria which has been in existence now for over five (5) years has served employees in the formal sector. Despite these laudable aims of NHIS, evidences on ground seem to suggest that a number of problems still militate against the scheme. Enrolees’ awareness of the scheme’s objectives and operations is may not be what is supposed to be. No proper health education efforts for the enrolees were being carried out; enrolees seem not to be aware of their rights under the scheme. This was indicated in the fact that complaints for redress were not being sought by consumers at the NHIS Arbitration panel. To the generality of Nigerians, access to healthcare is still very limited.  Despite the fact that the first phase of the scheme took off in the formal sector of the economy in 2005, consisting of workers in the Public services, accessibility to the healthcare insurance is still a major problem in many locations. Many enrolees who live in rural areas like the police find it difficult to have to travel distances since NHIS accredited Health Care centres are not available in all part of Anambra state, especially not in every LGAs. The extent of coverage of the NHIS is such that artisans, farmers, sole proprietors of businesses, street vendors, traders and the unemployed are not yet accounted for.

Healthcare financing burden still subsists in many service centres. Facts on ground show that enrollees are still being subjected to this problem. Many health care providers are not equipped with requisite manpower and up-to-date equipment to handle complaints of the consumers. Sometimes, prescribed drugs are not available, These leave the consumer with no other option but to seek alternative cash-and-carry health practitioners to treat him/her pending when he is reimbursed a month or so later. In emergencies where referrals cannot be quickly arranged, the consumers source their funds in order to get medical attention in referral hospitals without being reimbursed. This is so because the process of effecting referrals is quite cumbersome. All these increase the financial burden of the enrollees. Agba (2014) observes that long waiting of the patients during help-seeking for health care services tends to bore prospective users. He noted that the scheme has not been able to meet the health needs of the people and consequent upon which are evidences of occasional threat to health status. A casual visit to some of these Health care centres will reveal disenchantment on the faces of the enrolees, (Nwosu, 2010). Lack of qualified medical personnel remains a cog in the wheel of progress for NHIS. This is largely caused by the emigration of health workers abroad in search of better working conditions. According to Wikipedia, in 2005 about 2,392 Nigerian doctors were practicing in the United States of America, and 1,529 were in the United Kingdom.

Financing of public health services in Nigeria has been through government subvention funded mainly from earnings from petroleum exports and user fees for patients. Decline in funding for healthcare commenced after the mid 1980’s following a drastic reduction in revenue from oil exports, mounting external debts burden, structural adjustment programme and rapid population growth rate, Shaw (2005). The result as in most other developing countries was a rapid decline in the quality and effectiveness of publicly provided healthcare services. Funding of healthcare in Nigeria has not only affected the quality of healthcare services but led to impoverished health standard of the populace. The total expenditure on healthcare calculated in percentage of gross domestic product in Nigeria stands at 3.5% in 2005 to 6.04% in 2013 (olakunde,2013). It has resulted in the lack of facilities for the health sector; salaries are not paid leading to incessant strike action by doctor and other health workers. According to the President of Nigerian Medical Association Dr Enabulele, Nigerians have lost faith in the health care system of the country. And he went further to ask why he would enrol in a scheme when there are no hospitals around him. It is also pertinent to note that even when the allocation has been made available, financial misappropriation by unscrupulous financial experts leave the scheme with little or no working capital. This to a large extent limits the schemes ability to deliver quality and affordable healthcare.

• Objectives of the Study

The broad objective of this research is to assess NHIS operations in Anambra state. The specific objective of the study includes:

1. To examine the level of awareness of the NHIS programme in Anambra State.
2. Determine the level of accessibility and coverage of NHIS programme in Anambra State.
3. To determine the effort made by government towards funding health care centres under NHIS programme.
   • . Research Questions
4. What is the level of awareness of the NHIS programme in Anambra State?
5. What is level of accessibility and coverage of NHIS programme in Anambra State?
6. What efforts have been made by government towards funding health care centres under NHIS programme?

• . Hypotheses of the Study

Hypothesis one

H_o: There is a high level of awareness of the NHIS programme in Anambra state.

H₁: There is a low level of awareness of the NHIS programme in Anambra state.

Hypothesis two

H_o: There is a high level of accessibility and coverage of NHIS programme in Anambra State.

H₁: There is a low level of accessibility and coverage of NHIS programme in Anambra State.

Hypothesis three

H₀: Government have made adequate effort towards funding health care centres under NHIS programme.

H₁: Government have made no effort towards funding health care centres under NHIS programme.

•  Significance of the Study

Empirically, this research work will be of immense benefit to the government of Nigeria, the various state governments and Anambra in particular. It will also be of great help to the management of NHIS.

To the Nigerian government, the study will help them to tackle the various identified challenges facing the Health sector, as well as aid them to effectively carry out a well articulated and planned health development in the country.

To the various state governments and Anambra state in particular, the study will help them to implement the compulsory enrolment of their staff and also in creating an enabling environment for the enrolment of their entire indigenes.

To the management of NHIS, the study will help them to embrace strategic planning and efficiency in management as they work hard to bring Nigeria to a level of Universal Health Coverage.

Theoretically, the study will add to existing literature on National Health Insurance Scheme in Nigeria. This will be very useful to students and other researchers that will in future investigate or do further studies on it, as a research material and will serve as a base for further research.  Finally, to the indigenes of Anambra and the entire citizens of Nigeria, the study will serve as enlightenment to them as regards the need for a health insurance.

• . Scope of the Study

This study focuses on the policy of National Health Insurance Scheme in Nigeria, its effect, challenges and prospect with particular reference to Anambra State.

• Limitations of the Study

In the course of carrying out this study certain factors proved to be constraints to the researcher. The researcher faced challenges in gathering data relevant to the study. The NHIS in Anambra state had insufficient data as it pertains to its activities in Anambra state; thus the researcher relied on data gathered from Journals, published articles and the library. Gathering information from residents was almost impossible as many are not aware of NHIS.

Notwithstanding, the researcher was not deterred in his effort to produce an acceptable literature.

• Definition of Terms & Acronyms

1. 1. Financial: related to or relating to finance
   2. Funds: a sum or source of money.
   3. Government: the body with the power to make and enforce laws to control a country.
   4. Health Care: this can be defined as the prevention, treatment and management of illness or the preservation of mental and physical wellbeing through the services offered by medical, nursing and allied health professions.
   5. Insurance: A means of indemnity against a future occurrence of an uncertain event.
   6. NHIS: National Health Insurance Scheme. A scheme that was launched in 1999 to provide quality health care service at a reasonable cost through Insurance.
   7. NMHIP: National Mobile Health Insurance Programme. A programme of NHIS that allows subscribers of mobile network operators the platform to register, select Health Maintenance Organization and provider, and choose payment options and plan through their mobile phones.
   8. Programme: a set of structured activities.
   9. RCBSHIP: Rural Community Based Social Health Insurance Programme, established in 2010 to carry NHIS closer to the people.
   10. Scheme: a systematic plan or future action.
   11. UHC: Universal Health Coverage, a target of the World Health Organization for comprehensive health coverage for nations of the world.
   12. WHO: The World Health Organization.