OSOGBO, OSUN: As a civil servant at the ministry of human resources and capacity building in Osun State, Lateef Adebayo knew firsthand how corruption and poor implementation culture badly affected nearly all public policies in his state.
So when the Osun State government flagged off the so-called Osun Health Insurance Scheme or O'HIS in 2018, compulsorily enrolled all its civil servants, and started deducting a 1.5% premium from their basic salary, he saw it as another government effort to extort workers.
However, in the first quarter of 2019, Adebayo fell ill. Reluctantly, he picked up his O'HIS card and visited one of the accredited hospitals for the programme in Osogbo, the state capital where he lives.
The doctors diagnosed him with malaria and typhoid and gave him what he called "adequate treatment" in the form of drugs. He paid just 10% of the total bill after tendering his card as proof that he had O'HIS coverage.
The experience convinced Adebayo that the scheme was real and functional. He would have had to pay his entire bills out-of-pocket, and the cost would have been ten times higher.
Nigeria's health insurance failure
Over 90% of Nigerians do not have health insurance despite the existence of the National Health Insurance Scheme (NHIS) since 2004, meaning they pay out-of-pocket to access healthcare services.
Mohammed Sambo, NHIS's executive secretary, said in 2021 that its poor performance largely came from its establishing Act not making it compulsory. It was also overly formal sector-focused, leaving out informal sector citizens like casual and domestic workers, artisans and vendors, despite the informal economy covering over 60% of the national GDP.
However, last May, the national assembly successfully passed a bill that rebranded the NHIS into the National Health Insurance Authority, making the scheme compulsory for all Nigerians. But it is too early to measure the performance of the amended Act.
Local laws like O'HIS try to cover more people down the grassroots at the state level, but some states' schemes have performed poorly like their federal counterparts, due to weak implementation.
In Abuja, for example, less than 10% of those who enrolled for the FCT Health Insurance Scheme are from the informal sector. It is the same story in Delta State, where only 1.38% of the total enrollees belong to the informal sector.
How O'HIS works
To provide affordable healthcare services to all residents, O'HIS has provisions for civil servants, organized private sector, traders, families, and tertiary institution students.
While public civil servants are covered through the contribution of 1.5% of their basic salary and 3% contribution from the government, non-civil servants pay a premium of N12,066 or N57,600 yearly for individuals and families, respectively, to access the benefits.
An individual or family can register within minutes using an online application form. After enrollment, they are assigned to a health management organization or HMO that helps attach them to an accredited facility closest to them. HMOs are groups that purchase the rights to register enrollees with social health insurance schemes.
About 442 public and private health facilities have been accredited under the scheme, spanning from less-equipped primary healthcare facilities to better-furnished secondary and tertiary hospitals. Where a patient's need is beyond what the facility they are enrolled in can handle, their primary hospital refers them to a more equipped accredited facility.
Adesakin Olatunji, an OHIS desk officer at the University of Osun Teaching Hospital, said the scheme divides enrollees into primary, secondary and tertiary categories.
"Any patient that visits an OHIS accredited facility and is attended to by a general physician falls under the primary category. Such a patient is required to pay only 10% of the bills as the balance is covered by capitation. Osun Health Insurance Agency pays accredited health facilities N570 capitation per enrollee monthly depending on the number of enrollees under such a facility," Olatunji said.
"Patients with a reason to see a specialist [like an ophthalmologist or a surgeon] fall under the secondary category, while those whose diagnosis falls beyond the scope of their facility and have to be referred to a more capable health care facility fall under the tertiary category."
Patients under the secondary and tertiary categories are catered for through a "fee for service" policy. The policy mandates well-equipped accredited facilities to accept referred patients, treat them, collect only 10% of their bills, and later reclaim the remaining 90% from the Osun State Health Insurance Agency through their HMO.
Since 2018, at least 260,000 citizens have registered for O'HIS. Of those, about 100,000 fall under what Niyi Oginni, the Osun Health Insurance Agency executive secretary, calls "social register", which comprises the most vulnerable.
In May 2021, Mujidat Abiola, another civil servant living in Osogbo, was diagnosed with appendicitis. With severe pains ringing through her abdomen, her son rushed her to the former Ladoke Akintola University of Technology Teaching Hospital or LAUTECH (now University of Osun Teaching Hospital), an accredited facility, for surgery.
After the surgery, "We paid just N34,000 instead of over N300,000...for the operation, drugs from the drug centre and tests at laboratories," she explained. "We presented the financial sheet, all the receipts, the test results, and drug prescriptions at the admin block of LAUTECH O'HIS centre, and we were discharged. "
While the state celebrates its reach of 260,000 residents with the scheme, that number represents just 5% of the 5.2 million people in Osun State, implying poor performance. It is even worse for people in the informal sector, as just 2,000 informal sector workers have enrolled - less than 0.77% of the total enrollees for a programme that claims 'health coverage of all.'
But Oginni, the executive secretary of the Osun Health Insurance Agency, insinuates that residents' reluctance to enroll might be based on personal choice and not because his agency has not created enough awareness.
He said the agency uses Facebook, Twitter and sponsored radio programmes on local radio and television stations to create awareness across the state. He said it also engages selected HMOs and civil society groups to help market its benefits.
Another discouraging factor is the lengthy bureaucratic process it takes for some accredited facilities to reclaim costs incurred under the fee-for-service policy after treating referred patients.
The claim must be vetted by an HMO who investigates for any unwarranted charges. The hospitals must present receipts, test results, and the financial sheets they issued to patients. Some accredited private and public health centre desk officers said the investigation process could last for as long as three months.
This challenge sometimes affects the attitude of hospitals towards referred patients, especially in large public hospitals with high enrollees. But as part of efforts to encourage enrolments, the Osun Health Insurance Agency sometimes delists accredited centres found to be treating patients poorly.
This story was produced with the support of Nigeria Health Watch through the Solutions Journalism Network, a nonprofit organization dedicated to rigorous and compelling reporting about responses to social problems.