ABSTRACT
This research project raises some fundamental issues in health care financing strategies variously tried by the government and have all failed to achieve the desired objectives. Against which the National Health Insurance Scheme become an alternative to healthcare financing mechanism.
Some of the issues discussed in this project include:
1. How is healthcare financed
2. What is National Health Insurance Scheme
3. Objective of the Scheme
4. Concept and design of the scheme
5. Formal sector social health insurance programme
6. Rural community social health insurance programme
7. Urban self-employed social health insurance programme.
8. Permanently disabled persons social health insurance programme
9. Children under five social health insurance
10. Prison inmates social health insurance programme
11. How does the programme works?
12. Health care providers (HCP)
13. Primary health care provider
14. Fee-for-service healthcare provider
15. Health Maintenance Organization
16. Provider payment system
17. Operating the system
18. Prospects
19. Problems
– The Nigerian Factors
– Moral Hazards
– Cream skimming
– Quality assurance
20. Health care funding options
21. Accessibility
22. Monitoring and Evaluation and Policy target
These issues are not exhaustive but can be further explored in the various groups.
CHAPTER ONE
INTRODUCTION
1.1. BACKGROUND OF THE STUDY:
This document has been prepared against the historical background of the growth and development of the health services, the previous attempts to formulate national policies on health and the present state of the health services. The policy proposed and the strategies emerging from it have been based on appreciation of the current status of the health of the people of Nigeria, with a careful analysis of the major factors, which affect the health of the population, as well as the nature of interventions, which can produce improvement most rapidly and economically.
The increasing cost of drugs and infrastructure and the mobility of all individuals, corporate bodies and nations to conveniently meet the costs due to the pressures of other necessities – political, economic, social and education – have stimulated the search for other means of finding health care.
Risk of accident and sudden illness are part of the elements involved or in everyday activities of human life which is not speculative but pure risk or fortuitous. The accident or ill-health can cause disability which can be total leading to permanent loss of income, and greater economic loss than that
produced by death, as the disabled still requires. Most necessities like food, housing and they very expensive medical care, cost of which will seriously erode the family’s fortune, and standard of living. National Health Insurance serves as definite one of a variety of approaches to healthcare.
We are now in an era where it is not only paramount for health care
delivery to be affordable, and accessible but also to be qualitative and sustainable. The delivery of health care, using the medium of a National health Insurance Scheme is a well tested and successful means of health care delivery worldwide.
1.1a. SOME WAYS OF MANAGING HEALTH:
– Reliance on assistance from other people especially relatives. This may never come and if it does, it is inadequate or late.
– Bearing the cost alone from own savings – could endanger the life of the person as the fund may not be readily available.
– Retaining the illness may go about with a lot of illness undiagnosed either because they are unaware (lack of knowledge) or they cannot afford the cost of treatment.
– Self-medication very dangerous and only suppresses for little while.
– Prevention (through personal hygiene, and good food, health maintenance, environmental sanitation etc) – though better than cure unfortunately, not all mishaps can be avoided.
– Protection which insurance provides is therefore a more practical and
economically sound technique o managing health risks like most others. Insurance system is a highly developed form of providence even when not adequately arranged as where there is under-insurance a reasonable cover is provided and the situation is reasonably controlled. By insurance arrangement, the small amount of contributions are pooled and are used to make good individuals’ incurred expenses within the approved agreed limit of benefit thus spreading their losses over a large group of people that contributed.
It follows therefore that the more contributions to the scheme, the less
the cost of funding or contributions to each of them which shows that insurance uses a technique based on the law of large numbers.
1.2. STATEMENT OF THE PROBLEM:
The State of Nigeria’s Health Care:
Nigeria was ranked 187th among the 191 UN member states by the World Health Organization (WHO) IN 2000. Nigeria is ahead only of the Democratic Republic of Congo, the Central African Republic, Myanmar, and Sierra-Leone.
There is no existing National Health Act that describes the national health service delivery system, and defines the health functionof each of the three tiers of government and the roles and responsibilities of all stakeholders.
Resources allocation is inefficient and unbalanced between the three
levels of care (Federal, State & LGA). Nigeria has one of the lowest national health budgets in Africa. The country spends approximately US$4.00 per capital on health, versus US$14, which is the global minimum recommended by WHO for developing countries. The quality of health services and facilities is very low. Service facilities at all levels are dilapidated, under funded, and poorly equipped with obsolete equipment. The referred system is largely non functional.
– Consumers are dissatisfied with the quality of health care available.
Because they are generally uniformed and unaware of their rights and responsibilities, they are unable to either demand their rights or act on their own obligations for maintaining good health.
– Fake, substandard, adulterated and unregistered drugs are the norm in the market. Supplies of safe and affordable essential drugs and other consumables are erratic at best.
– Human Resources management is very poor leading to inefficiency and
poor service delivery.
– The weak service delivery system is unable to deliver a minimum package of quality health care including routine immunization, emergency obstetric care, prevent and management of communicable diseases and infections especially malaria, tuberculosis and HIV and AIDS.
– There is a minimal relationship between he public and private Health sectors.
The situation in Nigeria is that many of our people especially women and children in particular, the poorest of the poor die from avoidable health problems such as infectious diseases, malnutrition, complications at child birth and pregnancy. All the data show that health services in Nigeria have suffered from decades of neglect, endangering every Nigerian’s health. It is
against this background that new policy to embark on National Health Insurance Scheme become a good alternative to health care financing which as we all know, has been a failure.
1.3. OBJECTIVE OF THE STUDY:
1.3a. The state of the Health Services
The health services as currently organized show major defects which are widely recognized:-
(i). The coverage is inadequate. It is estimated that no more than 35% of the population has access to modern health care services. Rural communities and the urban poor are not well served resulting for look for alternative health care services.
(ii). The orientation of the services is inappropriate with a disproportionately high investment on curative services to the detriment to preventive services.
(iii). The management of the services often shows major weaknesses resulting in
waste and inefficiency, as shown by the failure to meet targets and goals. With several different levels of governments, voluntary organizations and other agencies providing health care, the various inputs are poorly co- ordinated.
(iv). The involvement of the community i.e. minimal at critical points in the decision-making process because the communities are not well informed on matters affecting their health, they are often unable to make rational choices.
(v). The lack of basic health statistics is a major constraint at all stages
of planning, monitoring and evaluation of health services.
(vi). The financial resources allocated to the health services, especially to some priority areas, are inadequate to permit them to function effectively,
(vii). The basic infrastructure and logistic supports are often defective owing to inadequate maintenance of buildings, medical equipment and vehicles; unreliable supply of water and electricity; and the poor management of drugs, vaccine and supplies system.
(viii). Whilst this list is an accurate summary of the broad range of defects in the health services, there are also encouraging cases in which dynamic health and administrators, professional persons and lay members of the communities have successfully corrected these faults within their local areas. Such successful programmes provide useful models of what can be done with limited resources in spite of various constraints.
1.3b. THE STATE OF HEALTH OF THE POPULATION:
It is not possible to make an accurate assessment of the health status of Nigerians. This is because there is no system of collecting basic health statistics on births, deaths, the occurrence of major diseases and other health indicators on a country-wide basis, the best available estimates are obtained from a few centers where such data are collected, from sample surveys from institutional records and from special studies.
i. The limited health statistics indicate the general poor state of health of the population:
Crude Death Rate 16 per 1000 population Crude Birth Rate 50 per 1000 population Childhood mortality rate 144 per 1000 children Infant mortality rate 144 per 1000 children Life Expectance at Birth 50 yeas
(Sources: Nigeria Fertility Survey 1981 – 82 World Demography
Record).
ii. Some experts estimate that the infant mortality rate may be as high as 100 to 160 per 1000 live births in rural areas. Whichever figure is accepted, it means that out of every 12 children who are born alive, one or more of them dies before reading the first birth day. This rate is ten times as high as in most developed countries, it is much higher than in some other developing
countries which have a similar level of socio-economic development as in Nigeria. Child birth, which should mostly be a normal process with minimal loss of life, is associated with a significant mortality among Nigerian women.
13c. PATTERNS OF ILL HEALTH AND THEIR DETERMINANTS:
Most of the deaths and serious illness which occur among Nigerians are due to conditions which are easily preventable or which can be treated with simple remedies communicable diseases especially those which are associated with inadequate environmentally sanitations and poor personal hygiene predominate and are often compounded by malnutrition, lack of timely and appropriate care often increase the risk of serious complications in the course of minor ailments. The current high rates of morbidity and mortality can be substantially highly reduced by a more rational application of available resources, even at this time of financial stringencies.
1.3c.1. It therefore presupposes that National Health Insurance Scheme Policy as has been formulated in this context of those national goals and philosophy will go a long way to solve the problem of inadequate healthcare. Since health development contributes to and results from socio-economic development, the sectors shall be mutually supportive and together contribute to the ultimate goals of the nation. Health development shall be seen not solely in humanitarian terms but as an essential component as well
as being an instrument of social justice and national security. Therefore primary health care as defined in the Alma Ata Declaration shall be the key to the development of the National Health Insurance Scheme Policy.
1.3.d. Aagainst the above enurmerated misnormals, the objective of National Health Insurance Scheme have the following to offer as stated below:-
– To ensure that every Nigerian has access to good health care services.
– To protect families from the financial hardship of huge medical bills.
– To limit the rise in the cost of health services.
– To ensure equitable distribution of health care cost among different income groups.
– To maintain high standard of health care delivery services within the scheme.
– To ensure efficiency in the health care services
– To improve and harness private sector participation in the provision of health care services.
– To ensure equitable distribution of health facilities within the federation.
– To ensure appropriate patronage full levels of health care.
– To ensure the availability of funds to the health sector for improve services.
1.4. RESEARCH HYPOTHESIS:
On May 24, 2004, the National Population Council (NPC) released the latest data from the Nigerian Demographic Health Survey (NDHS
2003). It is seen as the most accurate measure of the nation’s state of
health since 1990. The data does not make for comfortable reading. But it is a resounding wake-up call for immediate and compressive action.
BASIC HEALTH INDICATORS
INFANT AND CHILD MORTALITY (NDHS 2003 DATA)
Infant Death: There are an average of 100 infant death for every 1000 live birth (10%).
Child Deaths: For every 1000 children born 201 (or out of every five) children died before they were five years old (20%) Child Health (NDHS 2003 data). Only 13% of children aged 12 to 23 months have received the recommended course of immunizations. 23% of children have received no immunization at all.
Maternal Health: (NDHS 2003 data)
60% of women received antenatal care at least once from a trained health care provider. Two out of every three births happen at home. 17% of women have no assistance during delivery and 26% are assisted by an untrained person.
1.4b. MORBIDITY PATTERN:
The common causes of morbidity in Nigeria are still preventable infectious diseases. The common causes of visits at clinics and outpatient departments of hospitals and the relative percentages of these causes are shown in the table below:
1. Infective and parasitic diseases – 38.2%
2. Nutritional and Metabolic diseases – 1.8%
3. Respiratory diseases – 12.7%
4. Ill-defined condition – 9.2%
5. Skin diseases – 8.4%
6. Digestive System – 4.7%
7. Accidents – 3.1%
8. Muscles and Skeletal diseases – 2.9%
9. Genito-urinary diseases – 2.7%
10. Blood diseases – anaemia, etc – 2.5%
11. Diseases of nervous system and organ – 9.9%
12. Others – 3.9%
The causes for admission into hospitals and the relative percentages are shown below:
1. Infective and parasitic diseases – 31.3%
2. Nutritional and Metabolic diseases – 2.8%
3. Pregnancy and child birth – 23.1%
4. Respiratory diseases – 9.8%
5. Genito-urinary diseases – 5.8%
6. Accident – 5.3%
7. Digestive System diseases – 5.0%
8. Diseases of nervous system – 3.3%
| 9. Blood diseases | – | 3.0% | ||
| 10. | Ill-defined conditions | – | 3.2% | |
| 11. | Skin diseases | – | 5.0% | |
| 12. | Others | – | 5.0% | |
Common types of infective and parasitic diseases in order of occurrence are:
1. Malaria
2. Dysentery and Diarrhoeal Diseases
3. Measles
4. Pneumonia
5. Gonorrhoea
6. Whooping Couch
7. Schistosomiasis
8. Chicken pox
9. Tuberculosis
10. Meningitis
CAUSES OF MORTALITY:
The five most common causes of death in hospitals in Nigeria are very similar to those causing high morbidity. They are as follows:
1. Infective and parasitic diseases
2. Diseases of respiration system
3. Accidents, poisons and violence
4. Diseases of circulatory
5. Diseases of digestive system
1.5. SIGNIFICANCE OF THE STUDY:
Nigeria, with a current estimated population of 120 million, is expected to increase considerably in the next 23 years. This with continued migration to urban areas from the rural areas will give a concentrated client population easier access to health facilities and greater political demand for services.
With the improved educational system and fewer infectious and parasitic diseases, there is generally a trend to less focus on public health and primary health care issues to move on the upgrading health care issues.
With the expected improvement in health care services, lower infant mortality rate and longer life expectancy, there is a trend toward more hospital care, need for social insurance, more facilities, increased management efficiencies and specialized hospital care inculcating nursing homes.
Health insurance scheme is principally a health care financing mechanism
which invariably develops into the central character of the health system and thus influences provision, purchase, development and control of health services.
It goes on to cover the following elements curative care such as;
a. Output patients attendance
b.      Maternity care for up to four (4) live birth for every insured person.
c.       Consultation with defined range of specialists.
d. Hospital care in a public or private hospital in a standard word, during a
stated duration of stay for physical or mental disorders.
e. Eye-examination and care, excluding provision of spectacles.
f. Dental care as defined: Consultation, oral examination, preventive care and pain reliefs.
– Preventive care including immunization, family planning, antenatal care, post natal care and health education.
– Availability of prescribed drugs and diagnostic tests.
1.6. SCOPE:
The scheme when fully implemented will cover all Nigerians categorized as follows:
(i). Persons employed in the private sector; their contributions will be paid by/through their employers.
(ii). Persons employed in the public service; their contributions will be paid by through their employers, namely, Federal Government, State Government, Local Government, Parastatals and Agencies.
(iii). Self-employed persons (market women, traders, artisans, farmers and businessmen etc). This category will be encouraged to pay their contributions either by themselves or through cooperatives formed by them.
(iv). Vulnerable groups: These include the unemployed, the aged, the disabled, the street children, the retarded and the retirees, their contributions will be paid on their behalf by the federal government, state government and local government, NGOs, Local communities and philanthropists.
(v). Rural Dwellers not in categories I – iv) above. For this group suitably priced programmes designed for them will be implemented in consultation with various organizations such as community banks, cooperatives, local, state and Federal Governments as well as Donor Agencies and other NGOs.
However, contributions made by/for an insured person entitles him or herself, spouse and four children under the age of 18 years to full health benefits. But for students in school up to the age of 25 years qualify as dependents Extra contributions will be required for additional dependents.
1.7. LIMITATION:
The researcher was faced with the problem of finance to visit various offices and ministries that are involved in this scheme. Secondly, the occasional excuses by the officers (key) who would be of very important in giving useful information regarding the scheme and its implementation.
Again some of the insurance companies we think would have been able to give useful background regarding the cover as part of their policies they cover would turn you down by informing you that they are not actually involved in the scheme though its part of insurance business.
1.8. DELIMITATIONS:
One of the major problem faced by the researcher which would have been of very importance was how to get the statistics of the actual number death claimed by the enumeration as stated in the research hypothesis where data was presented in percentages without the no of death involve in each ailment presented. However the data presented was made possible from the publication obtained at one of the health institution library made possible by a seminar paper presented by one of the discussant.
This material content is developed to serve as a GUIDE for students to conduct academic research
NATIONAL HEALTH INSURANCE SCHEME AN ALTERNATIVE TO HEALTH CARE FINANCING
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