There are two African countries Nigerians like comparing their country with: Ghana and South Africa. While South Africa is industrialised and is easily Africa’s largest economy, Ghana is reputed for law and order as well as its entrenchment of democratic ethos and practice. Since 1992, when former President Jerry Rawlings transmuted from military to civilian president, Ghana has been able to alternate political power between political parties without bloodshed. That is a feat Nigeria has not been able to achieve. It is not a matter of pride: We have a lot to learn from our neighbours. I am not suggesting in any way that the Ghanaian example is near perfect. But they are making progress in so many areas that Nigeria is still lagging behind. One of such is the health insurance coverage for Ghanaian citizens.

In 2005, President Olusegun Obasanjo launched the National Health Insurance Scheme. To me, that is one of the best things the Nigerian government has conceived in decades. While there might be imperfections here and there, the concept is unassailable. It is meant to make health care delivery available to every Nigerian no matter their status. Millions of Nigerians are denied medical treatment because they do not have the cash. It is either they are too poor to pay or circumstances restrict their access to immediate cash. The ATM could fail at critical times. Medical emergencies can happen at odd hours. With the social health insurance scheme, the general idea is to make medical services available to NHIS enrolees anytime, any day and anywhere without cash transaction.

But as good as this scheme is, the snag is that less than five per cent of the Nigerian populace is covered by the health insurance scheme. Most of the enrolees are Federal Government workers (and their dependants) and a few employees in Organised Private Sector. Some communities have also keyed into the scheme. The Federal Government employees were practically coaxed into enrolling some years ago. The then head of the Civil Service of the Federation, Alhaji Yayale Ahmed, issued a directive making it compulsory for them to enrol. Initially, there was natural resistance from workers, who justifiably received the scheme with scepticism, having not had a pleasant experience with the housing contribution scheme. Up till today, states and local governments have refused to participate in the health insurance scheme, thereby denying millions of their workers and dependents the benefits.

However, I think there is so much we can learn from Ghana if we can swallow our pride and take a cue from an obviously smaller nation. The health insurance scheme in Ghana was conceived by Mr. John Kufuor when he was campaigning for the presidency in 2003. He personally felt there was no point continuing with the regime of cash-and-carry health care delivery system being practised in the country at the time. In fact, it was in the manifesto of his party, the New Patriotic Party. The manifesto was so detailed that it covered those diseases that were common to 90 per cent of Ghanaians. To make the scheme outlive those who conceptualised it, and in order to ensure its continuity, two major lists were made. One had all the conditions the scheme could cover, while the other had the excluded conditions.

The government came out with a minimum benefit package of diseases which every districtwide scheme was to cover for Ghanaian citizens. This package covered malaria, diarrhoea, upper respiratory tract infection, skin diseases, hypertension, diabetes and asthma. However, all districtwide schemes were given the right under the law to organise their schemes to cover as many diseases and services for Ghanaian citizens as they desire, provided it was approved by the National Health Insurance Council. Certain diseases were excluded from the benefit package because they were considered to be too expensive to treat. Other arrangements had to be considered for treatment. Diseases currently not covered are optical aids, hearing aids, orthopaedic aids, dentures, beautification surgery, supply of AIDS drugs, treatment of chronic renal failure, heart and brain surgery, etc. Interestingly, these constitute only five per cent of diseases afflicting Ghanaian citizens.

Having been able to overcome this issue of coverage, which was meant to ensure that the scheme did not become the exclusive preserve of those with sicknesses erroneously considered as those of the rich, Ghana moved to the next stage: the critical issue of funding. When the NPP won the Ghanaian presidency in 2004, the opposition National Democratic Congress criticised the scheme, saying it was meant for members of the new party in power, the NPP. Hence, the NDC did not encourage its members to register for the scheme. Even members of the ruling NPP erroneously thought too that it was for them alone. The controversy that initially surrounded the scheme at its inception was revisited in 2009 when the NDC now took over power and saw the benefits of the scheme beyond politics.

To fund the scheme, Ghanaians were made to register and pay according to the income of the enrolee. Like all insurance schemes, there were different types of contributions (private insurance talks about premiums, social insurance talks about contributions). To ensure that all Ghanaian citizens made some contribution to the scheme, a 2.5 per cent Health Insurance Levy on selected goods and services was passed into law so that the money collected could be put into a National Health Insurance Fund to subsidise fully paid contributions to the District Health Insurance Schemes.

While the Ghana version of social health insurance has been a story of success, the same cannot be said about Nigeria’s. A major difference is the structure of the country. Ghana runs a unitary system, meaning there is a central government that controls the affairs of the country. It was, therefore, easier to make every Ghanaian comply with the health insurance law. Nigeria runs a federal system, which means power is shared between the central government and the states. While the former head of service of the federation could direct all Federal Government employees to be part of the scheme, he had no such powers over state and council employees. With the current struggle over “true federalism”, the struggle to spread health insurance across the country is an uphill one. It is not surprising that no state is part of the NHIS programme yet. Millions of Nigerians are still receiving medical attention on a cash-and-carry basis.

The NHIS cannot cater for all Nigerians even as it seeks universal coverage. The fact is that it cannot muster the funds. Ghana has devised creative ways of funding the scheme, but the NHIS still depends largely on Federal Government’s contributions. The NHIS may have done well in enrolling over four million Nigerians, but there are over 100 million still waiting to be enrolled. Most are vulnerable and unable to pay contributions on their own. Somebody will have to pay on their behalf so that they can benefit from the package. Several suggestions are on the table to cater for those who cannot afford to enrol: a “sin tax” (on cigarettes and alcohol consumption), mobile phone call tax (one kobo per second), redistributionof VAT, and so on. The tragedy is that our political elite would not consider social health insurance as a desirable good for the poor, unlike the Ghanaian elite. Political will has seen to the success of social health insurance in Ghana while we are still dragging our feet in Nigeria. It is something to be ashamed of, if we ever decide to take stock.

- Dr. Johnson is a social health reform activist.

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