EIGHTY-YEAR-OLD Madam Angelina Emmanuel now enjoys free health care in a government health facility for the first time in her lifetime through the Basic Health Care Provision Fund (BHCPF).
After running some checks on malaria, typhoid and abdominal pains at the Garaku PHC One, in Kokona Local Government Area of the state in October, a health worker led her to the clinic’s pharmacy, where she received drugs to treat her ailments for free.
She was surprised that the services were free, just like the officials who enrolled her had promised her.
The officer-in-charge (OIC) at the PHC, Pauline John, told her the government would foot the bill. John said the aged woman would continue to enjoy the free services as long as she remained an enrollee under the government’s health insurance scheme.
The elated grandma confirmed to The ICIR reporter, who met her at the facility, that she paid nothing for the tests, drugs and consultancy card as she had to do before to access healthcare.
“Right from the registration point for this programme, they have not taken a penny from me. I’m happy that this is happening in my lifetime,” she said, urging the government to expand the scheme to cover everyone in the state.
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Because of the high cost of healthcare services in hospitals, Emmanuel only visited hospitals whenever herbal medication she prepared or got from neighbours could not save her from her ailments.
But that has changed since the health facility’s services are free.
“I only need to come to the clinic whenever I’m sick. I strongly believe I can live longer than I had thought with the programme,” the octogenarian told the reporter.
Similarly, the family of Joshua Kobi in the Obi LGA shared their experience of health insurance schemes in the state with The ICIR. They do not pay for services they receive at the Obi PHC One, where they seek care.
The family was enrolled on the BHCPF a few months after they had their twins in 2020.
Since the couple started enjoying the scheme, Kobi said he had been saving N10,000, the average money he coughed out from his small business to settle his family’s monthly healthcare costs.
While the government offers N12,000 yearly as a health insurance premium for individuals like the octogenarian Emmanuel, it pays N50,000 for a family comprising a couple and four children under 18 years, like the Kobis.
Yet another enrollee, eighty-six-year-old Madam Mainuna Musa, said the health insurance programme kept her alive.
She is hypertensive and also suffers from an ulcer. Before enrolling in the programme, she had spent so much in many hospitals, running tests and paying for drugs, many of which she could not afford.
But since she became an enrollee, she has received care at the Angwa Toni PHC in Lafia, the state capital.
A widow and a mother of four, she said the free health programme gave her respite and allayed her fears over the possibility of her ailments deteriorating.
“Here, they check my BP and advise me on what to do. They give me drugs. If there is any time I need to go to another hospital, they refer me. They do all these without collecting a penny from me,” she said.
The facility’s IOC, Aliu Muhammed, said the woman could receive free treatment for other conditions, including malaria and typhoid.
The Basic Health Care Provision Fund
Part 1, Section 11 of the National Health Act (2014) established the BHCPF.
The BHCPF is catalytic funding to improve access to primary health care. It serves to fund the Basic Minimum Package of Health Services (BMPHS), increase the fiscal space for health, strengthen the national health system, particularly at the primary health care (PHC) level by making provision for routine daily operation cost of PHCs, and ensure access to health care for all, particularly the poor, thus contributing to overall national productivity.
Sub-section 2 (a), (b), and (c) of Section 11 of the National Health Act mandates the Federal Government to commit an annual grant of not less than one per cent of its consolidated revenue fund into the BHCPF, which is augmented by other funding sources locally and internationally.
However, the Federal Government did not provide a budget for the BHCPF until 2018.
The National Health Act demands that before a state or local government can benefit from the fund, it must, among others, provide a counterpart fund of 25 per cent of what it will receive.
The Federal Government disburses the BHCPF across three gateways, according to the Act setting it up. They are the National Health Insurance Scheme (NHIS), the National Primary Health Care Development Agency (NPHCDA) and the National Emergency Medical Treatment (NEMT).
While the NHIS takes 50 per cent of the fund, the NPHCDA and NEMT get 45 and five per cent respectively.
Whereas the NPHCDA allocation is used for purchasing vaccines, essential drugs and consumables, as well as for maintaining the PHCs, and payment of workers, the NHIS uses its fund to provide the Basic Minimum Package of Health Services (BMPHS). The five per cent earmarked for NEMT goes for emergency responses.
FG’s budgets for BHCPF since 2018
In 2018, the Federal Government approved N55.1 billion for the BHCPF. The allocation was reduced to N51.2 billion in 2019 and N26.4 billion in 2020.
In 2021, the budget jumped to N35 billion and N44.5 billion in 2022.
Meanwhile, the BHCPF got N47.6 billion in the 2023 budget proposal submitted by President Muhammadu Buhari in October.
Following over a dozen investigations published by The ICIR, exposing corruption and other sharp practices in handling the BHCPF across 12 states in Nigeria, President Buhari ordered a probe into the fund’s management in October.
The BHCPF in Nasarawa State
As part of its preparedness to receive the BHCPF, the Nasarawa State launched its Health Insurance Agency (NASHIA) in 2018. The agency enrolled 10,000 vulnerable for health insurance in 2020 under what many people in the state know as Equity Fund. The initiative formally took off with the BHCPF in the state in 2021.
According to the executive secretary of the agency, Gaza Gwamna, a medical doctor, the Equity Fund convinced the Federal Government of the state’s commitment to health insurance and has made it to release nearly N500 million for the BHCPF to the state in two years.
Asked why the state enrolled people rather than contribute a 25 counterpart fund required by the law for any state to benefit from the BHCPF, he said, “The counterpart funding is like somebody is coming to your house. You have four children, and the person is telling you that you should enrol one child, and I will enrol three children for you. That is what the whole thing is all about. Nasarawa State has always met the condition.
He added, “We’ve enrolled over 10,000 from the state government funding, and Federal Government is coming to give us 28,600. The 10,000 we have is more than one-third of the 28,000. So, Nasarawa State has met all the criteria.”
He said the state was trying to see how its number could match that of the federal.
The two schemes started about the same time in 2021. The BHCPF had 16,000 enrollees that year and has covered additional 12,000 enrollees this year.
In total, there were 38,600 enrollees in the state as of October.
Gwamna told the reporter that each enrollee enjoys N12,000 premium per annum on both programmes, “as stipulated in the BHCPF guidelines,” while couples with four children under 18 years have a N50,000 premium.
He noted that at least one out of 147 political wards in the state offered health insurance services in compliance with the BHCPF guidelines, adding that the BHCPF was a catalyst for a positive change in the state’s health system, especially the PHCs.
How is the enrolment done?
Enrollees contacted by the reporter said the government registered them at the PHCs. Some were registered in 2020 and others in 2021.
They have an enrolment card bearing their names and other personal data, which they take to the PHCs to access healthcare services.
People in this category are either grouped into the BHCPF or the Equity Fund. Services are the same; only the institution paying the premium is different, many enrollees and OICs interviewed said.
Current enrollees in the scheme are mostly indigent persons, comprising the aged, orphanage children, and people with disabilities, among others, said Gwamna.
He said the state government had decided to include all civil servants in the scheme, who will pay a small percentage of their salary to enjoy the scheme.
He added that the state’s secondary school students would also be part of the scheme. The students will pay N3,000 annually to enjoy the initiative.
Meanwhile, individuals interested in the scheme but could not be covered by the governments’ fundings would pay the N12,000 premium on their own, while families would pay N50,000 annually, Gwamna told The ICIR.
Scheme creating disparities in PHCs
Some political wards in the state have up to eight PHCs, of which one renders health BCHPF or Equity Fund services.
Because they receive monthly premiums and other funds accruable to the schemes, PHCs which provide health insurance services are more financially buoyant and are more attractive. They enjoy higher patronage, have better infrastructures and pay their workers better.
The reporter noted that PHCs providing BHCPF services have better toilets and sanitation because they have more funds to pay cleaners and maintain toilet facilities.
The National Health Act makes these possible. Sub-section 3 (C) of Section 11 of the Act states that 15 per cent of the BHCPF shall be used to provide and maintain facilities, equipment and transport for eligible primary health care facilities. Part D of the sub-section also notes that five per cent of the BHCPF shall be used to develop human resources for PHCs.
For instance, contracted community health extension workers at PHC 1 Garaku, Model PHC Wamba, (Wamba LGA), Model PHC Toto, earn N10,000 monthly because the facilities offer BHCPF services, while their colleagues at PHC Tundu Gwandara (Lafia LGA), Daddere PHC and PHC Agwade (in Obi LGA) earn N5,000 or less because they are not designated BHCPF PHCs.
Other major challenges
One of the key challenges confronting the schemes is inadequate human resources for healthcare services.
Findings by the reporter showed that rather than a minimum of four midwives/nurses that the National Primary Health Care Development Agency (NPHCDA) recommends, most PHCs providing health insurance services have a maximum of two.
There are no doctors in any of the 17 PHCs in the 15 communities across five LGAs the reporter visited in September. None of the facilities had a trained nurse. Nine of the 17 PHCs provide the BHCPF or and the Equity Fund services.
The reporter was at the following PHCs in the state: Bukan Sidi, Tundu Gwandara and Angwan Toni PHCs in Lafia LGA; PHCs One and Two in Obi, and PHCs Deddere, Agwade and Ashupe in Obi LGA; and PHCs Marabban Gongo and Sisimbaki, and Model PHC in Wamba LGA.
He also visited Sabon Gida and Kokona PHCs and PHC One Garaku in Kokona LGA, and PHCs Shaffan Kwotto, Shaffa-Abakpa and Model PHC Toto in Toto LGA.
The chairman of the state chapter of the National Association of Nigerian Nurses and Midwives (NANNM), Tammah Shawulu, a nurse, told this newspaper that there were less than ten nurses and about 30 midwives in over 700 government-owned PHCs in the state as of 2020.
He explained that the government did not recruit health workers for ten years until 2021, when it absorbed graduates of the state’s School of Nursing and Midwifery.
The report on how inadequate manpower, especially midwives, cripples PHCs in the state can be found here.
Key challenges identified by enrollees and service providers
The Kobi family, who receives healthcare services at Obi PHC One said the facility would not give any costly drugs but would refer enrollees to buy outside the facility.
Similarly, another enrollee at the Garaku PHC One, Ibrahim Amadu, complained of space. He said there was no space for many patients who wished to stay as in-patients because of the need for health workers to monitor their health. He pointed at two beds the PHC kept outside for patients because of a lack of space.
According to the relation of an enrollee at the Model PHC Toto, Christopher Anthony, there had been no light at the facility for years. An assistant Officer-in-Charge at the facility, Hamisu Danladi, confirmed this to the reporter.
Danladi said the PHC uses lanterns at night for women in the labour ward. The reporter gathered there has not been light in the community for several years.
All the OICs of PHCs who spoke in confidence with the reporter said enrollees usually refused to go to other hospitals whenever they referred them.
The patients often complained that the hospital where they are referred would ask them to pay for services rendered, the OICs said.
Besides, the OICs said the money budgeted for each enrollee is insufficient to provide adequate care.
“You can imagine how much malaria and typhoid drugs are sold in the market today. Some are as high as N3,000. To treat malaria and typhoid, you may have to combine three or four drugs, including injections, which may take about N7,000 or more. This is a major constraint to the programme,” one of them said.
All OICs who spoke with the reporter said the government regularly released the BHCPF and the Equity Fund based on their enrollees’ population.
Some of the payments seen by the reporter showed that the government makes payments in different categories, including capitation and general maintenance.
At the PHC Angwa Toni, Lafia, there were 230 enrollees in BHCPF and 171 in the NASHIA (Equity) programme.
The OIC at the facility, Aliu Muhammed, said his facility got N131,100 and N99,000 separately every month.
A simple breakdown of the amount received (N131,100 for 230 enrollees and N99,000 for 171 enrollees) showed N570 and N579 going into each enrollee’s treatment for the BHCPF and the Equity Fund, respectively.
The remaining amount (about N621) goes into human resources development and facility maintenance, as stipulated in the National Health Act.
Community engagement and accountability
The State Commissioner for Health, Ahmed Yahaya, said the government engaged people of host communities as OICs of the PHCs to ensure community participation and accountability in the programme.
Virtually all the OICs interviewed by the reporter confirmed that they were from the community where their PHC is located.
The Executive Secretary of the state health insurance agency, Gwamna, said, “the community participates in the process, including periodic meetings with the enrollees and enrollees service providers interface.
“It is structured in a way that you have the Ward Development Committee. We have the chairman and other excos. They are aware of how the utilization of funds goes. We get a monthly report from them. The monthly report comes through the local government areas, and we get it here.”
Many people are unaware of scheme in the state
The ICIR spoke with a cross-section of people in the state who said they were unaware of the health insurance programme.
Ganiyu Ismail lives at Kokona, in Kokona local government. He told the reporter he was hearing of the scheme for the first time when requested to air his view over it.
Labaran Mattew, a resident of Toto, also shared the same opinion.
Some couples contacted said the premium was too much for them to pay, except the government enrols them.
We are engaging more health workforce – Commissioner
The health commissioner told the reporter that the state governor, Abdullahi Sule, an engineer, had directed that over 200 health workers be absorbed into the state primary health care facilities.
In addition, he said the governor had directed that all graduates from the state School of Nursing and Midwifery interested in working with the state should be employed.
Health insurance our priority – Executive Secretary, NSHIA
Executive Secretary of the state health insurance agency, Gaza Gwamna said the state priority for health insurance was for the vulnerable.
He said since there were no resources to enrol all people in the state, the government concentrated on the vulnerable.
“In Nasarawa State, we use economically disadvantaged people because there are poor and downtrodden. We have those that we feel are aged. We have the disabled group, and there is a special school here in Lafia that is a school for the disabled. All of them are covered.
“We also have a group of people who found themselves in orphanage homes, which is not their fault. All the orphanages, as long as they are registered with the state Ministry of Women Affairs and Social Development. We also have a programme that takes care of the lmajiris. We have many of them who are enrolled and enjoying the scheme.”
He decried the use of the state’s 2006 population as a major criterion for approving BHCPF to the state. Using the population for determining what comes to the state from the fund shortchanges the state, he stated.
He added: “I must say that this funding is really not sufficient for people that really need the services. That is why we are happy that NHIA (National Health Insurance Authority) is making efforts to raise funds from different sources.
•This report is supported by the International Budget Partnership and the International Centre for Investigative Reporting (ICIR).
Marcus bears the light, and he beams it everywhere. He's a good governance and decent society advocate. He's The ICIR Reporter of the Year 2022 and has been the organisation's News Editor since September 2023. Contact him via email @ mfatunmole@icirnigeria.org