Recently, the National Health Insurance Scheme (NHIS) moved to extend cover to community dwellers, tagged Community Based Health Insurance Scheme (CBSHIP). The executive secretary, Mr Waziri Dogo–Muhammed in this interview with WINIFRED OGBEBO talks on the coverage for the informal sector, including the vulnerable group, and how far the scheme has fared till date.
What’s your take on health¬¬ financing, especially in view of the way the scheme is being operated in Nigeria?
Many countries are grappling even to start. Many are thinking how to go about it, and we have a lot of experience to share with them. Our approach, not by design, so happens that we are phasing it. There is no way you can get the whole country covered at once. So we are able to have a phased implementation, and we are able to engage the formal sector, which is quite definite, it has resource we can predict. We are able to learn by rolling that out. And when we stumble over the maternal and child health insurance, which is a community-based insurance, we are running now for two years, we are able to have a taste of the community-based one if we are to go. And many people are saying budgeting for health has doubled in the last five years or so, but over eighty per cent of it is donor -driven, it is not in-country. So you find out we have to have a home-grown way of financing health for the people. And even today you have seen the budget of WHO itself for our region is threatened, because with the global financial meltdown, you find that donor contributions, which used to be eighty per cent and only about 19 to 20 per cent by the African countries themselves. Most of the programmes of WHO, at least in our region, are threatened. What we are saying is: every country should try to be more innovative and find ways in which they can cover. Until you can cover all those who are excluded, all these things we are talking about—health indices, which are getting worse will continue to get worse. If we say we are going to rely on foreign people to come and finance our health, I think we are not getting it right. It can’t be. It has to be the social health insurance way, where people will take responsibility in one way or the other and government comes to create the enabling environment by producing the ways, how different groups can be covered, and that’s why you have to have different products, so that people have a choice. You can take the one that fits you, is it the community health, the voluntary contribution, vulnerable group, like that.
There are certain issues on out-of-pocket payment. In Nigeria, we are emphasising on pooling system. Since the scheme was established, we have not had contributions from even the civil servants. Why?
Out of pocket is what everybody is trying to run away from because in Nigeria, it stands at about 60,70 per cent out of pocket, direct from the individual at the point of accessing care. And that’s what health insurance tries to address. But some of the financial burden, because of the level of poverty among the informal sector group we are talking about, they are denied access—they can’t pay and they resort to other ways of accessing care: traditional, going to the patent medicine store to just buy whatever. So with that the disease keeps on eating people. At the end it becomes a big monster and may consume them. So out of pocket is what we are trying to go away from. Not only that, user fee is another thing also being discouraged. It is just like the revolving fund, trying to recoup the price for what you have purchased and a little bit on top for administration. That will also have to move away. And the best approach is by selectively engaging the population. If you identify economic groups in a country, you can have their own programme. In Nigeria, we did a nationwide inventory of all cooperative groups. These are group of Nigerians who have some economic activity. If you say because you have some economic activity, what disease bothers you, then we will be able to say it may cost so much, and you can make token contributions once a while and when you are sick you come and access care almost awoof [free]. It is by doing this that the country can identify the groups that are excluded and cannot afford, and then Nigeria will have to find [ways to fund them]. Of course there are many innovative ways. We have a lot of hope in the national bill [on health]. We think if that bill is passed, Nigerians should have a minimum benefit package. That’s why we are hopeful that with the two chambers signing it and then Mr President. We really think he will sign it into law and that will do the trick for all of us.
What can we take from here?
Nigeria is on track. We have started it, we have the experience, and even other countries that are giving example like Rwanda and Ghana, have their own problems. Because in Rwanda, I think about eighty per cent is donor funded. In Ghana also they have a problem, because the value added tax is unpredictable. So one has to look for more innovative ways of financing health. What I am going away with here is: if people think there will be donor funding for your [health], forget. You have to sit down and look at the innovative ways you are going to use to mobilise resources so that you give cover to the whole country. In Nigeria, we are talking about the National Health Bill. In recent times, we are talking about airtime. I have heard Gabon, which is already using the mobile phone to mobilise resources, and they are comfortable with this. In Nigeria, if we can just take one kobo per second: with eighty million lines in the country, that’s one hundred and eighty million naira everyday—that’s about N14.4 billion every month and N172 billion naira annually. That is five times more than the national health bill when it is passed. We think that’s the way we can look at it, and it is user friendly. The empire will keep on rolling; more Nigerians will buy more lines.
How far have you gone with that?
We have already written a concept paper and sent it to the minister of health, and any forum we go, we sync it. When the pan-African summit took place in Abuja, we spoke about it. We are trying to engage other ministries. We are stuck with the minister of Finance, and so with all those people, the federal inland revenue service so that we will know how to capture this money. I think it is doable
Let’s talk about your parties
I have been to India and Kenya. Kenya is the first African country to start health insurance in 1966, that’s over 40 years. They have just covered 7% of their population. And they are only giving care at hospital level. They don’t give primary level of care. I went to India. The government is giving free care, hundred percent, to all the poor and collaboration between state government and the province is 100 per cent but only hospital care is given. Primary level of care is left to the individual. Nigeria is a different ball game. We recognise that 70% of our diseases are at primary level. NHIS covers that 100 per cent, and that’s the basis of our mechanism for capitation. And it is more expensive than fee for service. Because we are 550 for primary level of care but only 91 naira for secondary and tertiary level of care. So you can see more than six times we are paying more than that money at primary level of care and that’s where the money is being pumped to strengthen our health system. It is only in Nigeria that it happens. We have taken care of primary, secondary and tertiary level of care with few exclusions. The reason why there must be exclusions is that there must be resources to back up whatever benefit package you want to give. I have heard people saying you are not covering cancer, renal disease, dialysis—that is what people want. HIV and TB are not covered because government is paying. So you cannot make double provision. Take cancer.
Recently, I brought all the incidences in our hospitals and we took the top 20 diseases. Do you know where cancer is? 0.48%. So if you want me to factor in cancer, it means it has a very high incidence , you will put some money on behalf of everybody that will have cancer of one thing or the other. What will happen to the contribution? It will be too expensive. The same thing when you take renal failure, dialysis. How many people reach renal dialysis? I was once in a hospital in Adamawa and I asked them how many patients were dialysed? They said two per month. What is the population of that state? Four million? You are talking of two people. When you look at social health insurance, you look at the commonest diseases. And in Nigeria, by the time you say malaria, gastroenteritis, upper respiratory tract infections, skin diseases, worms for children, hypertension, diabetes, over 90% of the disease burden is covered.
Source leadership.ng/
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