National Health Insurance Authority Act and mandatory health insurance

The National Health Insurance Authority Act was enacted in 2021 to repeal the National Health Insurance Scheme Act, to ensure the effective implementation of the National Health Insurance Policy that would facilitate the attainment of universal health coverage in Nigeria. This discourse reviews the idea of health insurance and its link to universal health coverage as well as the reasons informing the mandatory health insurance scheme. It seeks to point out that our laws are getting progressive whilst implementation seems not to be at par with the intention of the legislature.

S. 1 of the NHIA establishes the NHIA while S. 3 provides for its functions to include, but not limited to, promote, integrate and regulate all health insurance schemes that operate in Nigeria; ensure that health insurance is mandatory for every Nigerian and legal resident; and enforce the basic minimum package of health services for all Nigerians across all health insurance schemes operating within the country, including federal, states and FCT as well as private health insurance schemes. Others are to promote, support and collaborate with states through state health insurance schemes to ensure that Nigerians have access to quality health care that meets national health regulatory standards; and ensure the implementation and utilisation of Basic Health Care Provision Fund as required under the National Health Act and any guidelines as approved by the minister under that Act. S. 3 (b) of the NHIA Act, under the functions of the Authority, provides for the NHIA to ensure mandatory health insurance for every Nigerian and the country’s legal residents.

Health insurance is an insurance contract taken to cover the cost of medical care. The contract can be annually, monthly or over other fixed and certain periods of time. It typically caters for health care expenditures such as medical, surgical, prescription drugs, dental and other expenses incurred by the insured.

It is imperative to note that health insurance can be comprehensive or apply to a limited range of medical services. It may provide for full or partial payment of the costs of specific services. This is usually dependent on the quantum of the premium. Health insurance can reimburse the insured for expenses incurred from illness or injury treatments accessed or pay the health care provider directly. It ensures that individuals and families have access to health care services without any financial difficulty as opposed to out-of-pocket expenditure.

The major difference between health insurance and out-of-pocket health expenditure is that the latter insists that patients pay upfront to access health care services whilst health insurance provides the insured (or enrolees) access to health care services which payments would be settled from the pool of contributions (premiums) paid by all the insured in the health plan. The salient elements that are basic to all the health insurance varieties include: advance remittance of premiums into the pool, gathering funds together, and being eligible to enjoy the benefits for payment of premiums made, or for being employed in situations where employment entitles a person to enjoy the benefits of health insurance.

There is a distinction between health insurance and publicly funded healthcare system, which provides coverage for every citizen or resident under a free healthcare program.  For instance, healthcare services available to indigent and poor persons by the Basic Health Care Provision Fund under S.11 of the National Health Act are not based on any premiums/insurance system but are funded through the statutory one per cent of the Consolidated Revenue Fund of the Federal Government.

The World Health Organisation defines universal health coverage as a situation where everyone has access to the health care services they require, at the time and place they require them without financial hardship. UHC connotes a scenario where all persons and communities have access to the health services they need, at the necessary time and where they are needed without financial hardship. The services being referred to include: essential health services ranging from health promotion to prevention, treatment, rehabilitation and palliative care.

To deliver these services, sufficient and capable health and care workers with optimal skills mix at facility, outreach and community levels are needed; they are to be evenly distributed and appropriately supported. UHC strategies enable everyone to access the services that address the most significant causes of disease and death in their society and also ensure that the quality of those services is good enough to improve the health of the people who receive them.

UHC safeguards all people from public health risks and protects all people from impoverishment due to illness, whether from out-of-pocket payments for health care or loss of income when a household member falls sick. Full-scale expansion of health insurance is pivotal to the attainment of the above goals. Improved health outcomes are hinged on the possibility of attaining UHC in that as more persons are covered, their basic health needs are met. Protecting people from the financial hardship of having to make out-of-pocket expenditures for health services reduces the risk of their sliding into poverty when unexpected ill-health necessitates using up life savings, selling assets, or even borrowing, etc.

Against the background of the foregoing, there are a plethora of reasons in support of compulsory and universal health insurance schemes in Nigeria. They are: to achieve universal health coverage, financial risk protection in accessing health care, introduce equity in financing health care and facilitate the implementation of the minimum core obligation of the state on the right to health. Others are to reduce the financial burden on the government, guarantee sustainability and credibility of health financing, facilitate the whole-of-society approach to health and set the building block for a vibrant and healthy population. Furthermore, health insurance is a means of poverty eradication, reduces inequality and uplifts the low strata of society.

However, despite the mandatory nature of the scheme, there will still be citizens who due to their special financial and physical circumstances, may not be able to afford the premium to make them eligible to be covered by a health insurance scheme. This is where the core obligation of the state on the right to the highest attainable state of physical and mental health kicks in to ensure that special equity funds established under the law will fill the gap. This ensures that such persons access at the very minimum, the minimum package of care provided in the National Health Act.

We now have a beautiful federal law on health insurance which is complemented by various state-level laws. These subnational laws also provided for compulsory and universal health insurance. Considering that insurance is item 33 on the Exclusive Legislative List of the 1999 Constitution, federal law will take precedence in the event of any conflict. What is now outstanding is the political will at the highest levels, expertise and capacity of the various executive and implementing agencies across the federation to ensure that the new regime of compulsory health insurance translates to improvements in universal health coverage.