The Health Insurance Scheme 1

The health Sector has been inundated with challenges of patronage, poor service quality, revenue generation, recovery of cost of treatment for emergency patients and accident victims and most importantly cost of keeping the facility running. Like every business, most healthcare practitioners are at a cross road of which one comes first: financial gains or their core value of saving lives. Most prefer the financial gain! I fully agree that bills will have to be paid while giving sufficient return to the operators. However, providing stabilization and the joy of saving a life I believe should give better satisfaction and sense of fulfillment.

The economic situation has further compounded the condition of the sector as quite a sizeable number of people (especially the lower income cadre) have shifted to self-medication/abuse, patronage quacks/unqualified nurses or are forced to become their own doctors due to high cost of healthcare, which has also led to high mortality rate.

Health Insurance, under the supervision of the National Health Insurance Scheme, is meant to bridge this gap by offering the healthcare facilities the opportunity of increased patronage and financial gains/Return on Investment while providing accessible, affordable and qualitative healthcare to the general populace without putting a hole in their pockets.

What is Health Insurance?

Health Insurance is a system that allows the enrollees (insured) to pay in advance for health expenditure that might likely occur during a stipulated period (usually a year) through the payment of premiums into a common pool to pay for all or part of health services specified by a policy or plan. Health Insurance can be broadly categorized as social or private health insurance. In essence, Insurance allows the insured to substitute a small but definite cost (premium) for a large but uncertain risk.

In this country, experience has shown that monetizing healthcare and direct fee-for-service systems of healthcare financing has not addressed or solved healthcare problems. The funds are usually directed at other unrelated issues and when the need arises, it becomes difficult sourcing the funds. Similarly, out of pocket payments have failed to promote utilization of health care services for early detection and treatment of disease. This system of payment also causes a lot of financial hardship for the patients.

The Federal Government consequently set up The National Health Insurance Scheme, which was established by (NHIS Act 35, of 1999) to address some of these issues and to provide an opportunity for all to access quality healthcare irrespective of your class and societal background.

The Scheme provides for the Principal enrollee, the spouse and 4 (four) biological children while any other can be added as additional dependents but at an additional cost.

Parties involved

The Scheme is structured around 5 (five) key participants:

1.      National Health Insurance Scheme (NHIS) - the regulatory body

2.      Health Management Organizations (HMO) – a private sector operator that anchors the   program (likened to an Insurance Company)

3.      Healthcare Facility Providers – Hospitals that provide the healthcare services

4.      Employer – corporate body, associations, unions, government agencies, families, etc.

5.    Beneficiaries (enrollees) – those that stand to benefit from the scheme; father, mother,  children, dependents, etc.

The products or service available are categorized under two sectors for ease of operation and accessibility:

1.   Formal Sector Social Health Insurance Program

The Sector Social Health Insurance Program is compulsory for organizations with 10 or more staff and usually involves the employer and employees pooling their contribution (though most private sector organizations offer this to their staff either from the medical allowance or as an added incentive) to provide Primary (preventive, curative and rehabilitative services), Secondary (specialized services to patients referred from the primary healthcare) and Tertiary (highly specialized services based on referral from the secondary care level) healthcare for the employees and their families. The Formal Sector includes:

·     Public Sector (Federal, States and Local Governments)

·     Organized Private Sector

·     Armed Forces, Police and Other Uniformed Services

·     Students of Tertiary Institution Social Health Insurance Programs (current being extended to primary and secondary schools of either privately or publicly owned with or without a sick bay)

2.      Informal Sector Social Health Insurance Program

This is a social health insurance program system for people in the informal sector of the economy. It covers employees of companies having less than 10 employees, artisans, voluntary participants, rural dwellers and others not covered under the Formal Sector. Two of the service provided under this scheme will be reviewed for now:

·    Community Based Social Health Insurance Programs: is a non-profit health insurance program for a cohesive group of households/individuals or occupation based groups, formed on the basis of the ethics of mutual aid and the collective pooling of health risks, in which members take part in its management e.g. societies, unions, cooperatives, etc.

·  Voluntary contributors Social Health Insurance Programs: (VCSHIP) is health insurance that is taken up and paid for at the discretion of willing individuals, self-employed individuals, retirees or at the discretion of employers on behalf of employee in organization with less than ten staff.  

Benefits/Coverage

Health Insurance provides coverage for the enrollee as indicated below but the depth/content of coverage and benefits to be enjoyed is however dependent on the type of the policy bought and premium paid.  The Healthcare facility chosen (it is advised that proximity should be a key factor in choosing one) is also a factor as referrals might be necessary to other facilities with higher capacity should the need arise.

S/N	BENEFITS	COVERAGE
1	Basic	Checkups, admissions, drugs, counseling, diagnosis, nursing, etc.
2	Pediatrics	Nursing, child welfare, immunization (primary/secondary), consultation
3	Gynecological	Pre & post natal, up to 4 deliveries (normal or otherwise), family planning, consultation, etc.
4	Surgery	Consultation, minor or intermediate surgery, appendectomy, etc.
5	Investigation	Laboratory test, X-rays, radiological, ultrasound, routine and specialist investigation
6	Dental	Primary care, simple extraction, dental surgical extraction, filling, scaling, etc.
7	Ophthalmology	Basic eye test, eye treatment, surgeries (cataract), provision of glasses, etc.
8	Emergency	Evacuation, stabilization, ambulance services, mental illness, STDs, facilitate overseas treatment, etc.

Conclusion

The choice is completely yours as you get to decide the Health Management Organization to partner with, the Healthcare Facility, the policy type, depth of coverage, premium payable (starting from N15,000/person per annum) and the number of dependents to cater for.

The general argument of “I don’t fall sick” might be true for some but what of your children, family members and your aged parents. Health insurance provides the cushion and peace of mind that your family members are covered even when you are not physically present. Location is not a barrier as you can choose 2 facilities to cater for you and your family even while on a trip.

Cost of the care is no longer a bother as the HMOs foots the bill as long as the premium has been fully made, which is quite minute when compared to the actual cost of treatment. There is also no limit to the frequency of visit.

Health is wealth, take a policy today!

For further information or input/request for assistance on type of policy, depth of coverage and premium payable, send a mail to info@emoyolgroup.com or info@bizadvisory.tk

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Mr. Michael Ajayi is a Graduate of Management, Banking and Finance with over 22 years working experience spanning banking, insurance (life, general, health and travel), trading, procurement, management consultancy services, training etc. He is the Chief Executive Officer of Emoyol Group (www.emoyolgroup.com) involved in Business & Financial Management, HR Out-Sourcing, Insurance Advisory and Property Management. He has worked and collaborated with various professionals’ (individuals and organizations) over the years in the area of Training, Consulting and Business Advisory Services.