NHIS Nigeria: 3 levels of cover, objectives and benefits

What is NHIS

National Health Insurance Scheme (NHIS) was set up as a Public-Private Partnership to provide accessible, affordable, and qualitative healthcare for all Nigerians.

Participants of the NHIS scheme are to make contributions into a common pool to be able to have access to social health insurance. A fixed amount (usually a token) is paid regularly (monthly for salary earners) whether the contributor falls sick or not. However, whenever a contributor needs medical attention, the Health Maintenance Organisations (HMOs) pays from the pool of funds, a large percentage of the cost of healthcare.

This pre-payment plan is primarily a risk sharing arrangement which can improve resource mobilisation and equity. It is indeed regarded as the most widely used form of health care financing worldwide.

NHIS also regulates private health Insurance operated by HMOs. HMOs do have a hyperlink to the HMOs list on the NHIS site

Objectives of NHIS

The objectives of the National Health Insurance Scheme (NHIS) Scheme are to:

• Ensure that every Nigerian has access to good healthcare services:
• The participant already has access to a healthcare provider even before they fall sick.
• Protect families from the financial hardship of huge medical bills:
• Illnesses are usually unplanned. Paying out of pocket whenever the need arises can bore a deep hole into individual pockets especially in chronic and terminal health conditions. There are situations where a family would become homeless or loses a business/company because they had to raise huge sums to offset enormous medical bills.
• Limit the rise in the cost of healthcare services: The scheme has a fixed amount that is paid to access various healthcare services, although this is to be reviewed from time to time.
• Ensure equitable distribution of healthcare costs among different income groups: Higher-income groups contribute larger sums than low-income groups. Both groups, however, have equitable access to needed healthcare services.
• Maintain a high standard of healthcare delivery services within the Scheme.
• Ensure efficiency in healthcare services
• Improve and harness private sector participation in the provision of healthcare services: NHIS also accredits private health facilities to be part of healthcare providers under the scheme.
• Ensure adequate distribution of health facilities within the Federation
• Ensure equitable patronage of all levels of healthcare: this includes primary healthcare centres (PHC), secondary healthcare institutions like the general hospitals and tertiary healthcare institutions like the teaching hospitals.
• Ensure the availability of funds to the health sector for improved services.

The Act that established NHIS states that the Scheme shall be responsible for

• Registering health maintenance organizations (HMO) and healthcare facilities (HCP) under the Scheme
• Issuing appropriate guidelines to maintain the viability of the Scheme
• Approving format of contracts proposed by the health maintenance organizations for all health care providers
• Determining (after negotiation) capitation and other payments due to healthcare facilities, by the health maintenance organizations: Capitation is the amount of funds paid to an HCP by HMO per month. It is usually calculated based on the number of people that are registered under the scheme in each health care facility. For instance, a healthcare facility that has 100 participants with capitation of #1000 per month, for instance, would have #100,000 paid to them as monthly capitation whereas a facility with 578 participants would get #578,000 as monthly capitation. It is very unlikely for all participants in a particular facility to access healthcare monthly. Hence funds are distributed monthly to cover those who accessed healthcare in the said month.
• Advising the relevant bodies on inter-relationship of the Scheme with other social security services
• The research and statistics of matters relating to the Scheme
• Advising on the continuous improvement of quality of services provided under the Scheme through guidelines issued by the Standard Committee
• Determining the remuneration and allowances of all staff of the Scheme
• Exchanging information and data with the National Health Management Information System, Nigerian Social Insurance Trust Fund, the Federal Office of Statistics, the Central Bank of Nigeria, banks and other financial institutions, the Federal Inland Revenue Service, the State Internal Revenue Services and other relevant bodies
• Doing such other things as are necessary or expedient for the purpose of achieving the objectives of the Scheme under this Act.

In order to ensure that every Nigerian has access to good healthcare services, the National Health Insurance Scheme initially had programmes to cover only the formal sector, that is government workers, the organised private sector for example commercial banks and students of higher institutions. However, the informal sector social health insurance programme which was recently launched.

FORMAL SECTOR SOCIAL HEALTH INSURANCE PROGRAMMES

• Public Sector (Federal, States and Local Governments)
• Organized Private Sector
• Armed Forces, Police and Other Uniformed Services
• Students of Tertiary Institution Social Health Insurance Programmes
• The scheme does not cover those who have retired, for now, however, some organisations make provisions for their own retirees and bear the cost.
• Recently, a program was launched for retirees of the Nigerian police force and contributions are to be made by the force on their behalf.

INFORMAL SECTOR SOCIAL HEALTH INSURANCE PROGRAMMES

a) Group, Individual, Family Based Social Health Insurance Programmes (GIFSHIP) has now been launched.

Benefits of NHIS

 BENEFIT PACKAGE FOR (FORMAL SECTOR SOCIAL HEALTH INSURANCE SCHEME)

The NHIS has a Standard Treatment Guideline and Referral Protocol that must be followed when enrolees present to the HCPs. There is also a drug List and NHIS Diagnostic Test Lists which captures the drugs and tests that are covered by the scheme and if the drug or test is not covered, then the enrolee would have to make out of pocket payments. Some anti-cancer drugs are included in the drug list but other treatment modalities like radiotherapy are yet to be included.

Healthcare Facilities under the Scheme are to provide the following benefit packages to the enrolees:

• Out-patient care, including necessary consumables (e.g. gloves, syringes, needles) as in NHIS Standard Treatment Guidelines and Referral Protocol  
• Prescribed drugs, pharmaceutical care and diagnostic tests as contained in the NHIS Drugs List and NHIS Diagnostic Test Lists.
• Maternity (ante-natal, delivery and post-natal) care for four pregnancies ending in live births under the NHIS for every insured enrollee in the Formal Sector Programme. This means that a woman who has three live deliveries and two miscarriages or stillbirths (giving birth to a dead baby) can still access maternity care under the scheme for subsequent pregnancy. Additional care is to be given if there is any stillbirth. All live births eligible to cover will be covered during the post-natal period of twelve (12) weeks from the date of delivery.
• All preterm/premature babies eligible to cover shall be covered for twelve (12) weeks from the date of delivery.
• Preventive care, including immunization, as it applies in the National Programme on Immunization, (NPI) health and family planning education
• Adult Immunizations viz. HPV, Hepatitis etc The NPI covers  for most immunisations up to the ninth month of life but additional vaccines like the chickenpox, mumps  and rotavirus vaccines etc are not covered.
• Consultation with specialists, such as physicians, paediatricians, obstetricians, gynaecologists, general surgeons, orthopaedic surgeons, ENT surgeons, dental surgeons, radiologists, psychiatrists, ophthalmologists, physiotherapists, etc.
• Hospital care in a standard ward for a stay limited to cumulative 21 days per year following referral.
• Eye examination and care, the provision of low priced spectacles but excluding contact lenses.
• A range of prostheses (limited to prosthesis produced in Nigeria)
• Dental care (excluding those on the Exclusion list).
• Annual medical check-up unrelated to illness

Note: “eligible to cover” as used above refers to a maximum of four biological children of the principal under the age of 18 years.

A further breakdown of the benefit package is presented below according to the three levels of care.

PRIMARY HEALTHCARE LEVEL

• Out-patient care (including consumables)
• Routine immunization
• Surgical procedures
• Internal medicine
• HIV/AIDS (management of Opportunistic Infections)
• STIs
• Mental Health
• Paediatrics
• Obstetrics and Gynaecology
• Ophthalmology
• Emergency care
• Family planning education
• Child welfare services.

Out-Patient Care

Services to be offered include proper history taking, examination and routine laboratory investigations to help reach a diagnosis. Laboratory investigations include malaria parasite, White blood cell count (WBC), Haemoglobin estimate or packed cell volume (PCV), urinalysis, stool and urine microscopy, Blood film for microfilaria, ESR, WBC-differentials, pregnancy test (urine), Blood grouping, Blood Sugar and widal test.

Immunization

Immunization against childhood killer diseases. The vaccines are BCG, Oral Polio, DPT, Measles, yellow fever, Hepatitis B, HPV and Vitamin A supplementation and other vaccines that may be included in the National programme on immunization from time to time.

Surgical procedure

• Drainage of a simple abscess (I&D)
• Minor wound debridement
• Surgical repairs of simple lacerations
• Drainage of paronychia
• Circumcision of male infants
• Passage of urethral catheter
• Other services as may be listed from time to time by the NHIS

Internal Medicine

• Malaria and other acute uncomplicated febrile illnesses.
• Uncomplicated Diarrhoeal diseases
• Acute upper respiratory tract infections
• Uncomplicated pneumonia
• Simple anaemia (not requiring blood transfusion)
• Simple skin diseases, e.g. Taenia Versicolor, M. furfur, T. Capitis, etc.
• Worm infestation
• Other uncomplicated bacteria, fungal, parasitic, and viral infections and illnesses
• Dog bites, snakebites, scorpion stings
• Arthritis
• Other illnesses as may be listed from time to time by the NHIS.

HIV/AIDS

• Voluntary Counselling and testing
• Health education
• Treatment of simple opportunistic infections

STI (sexually transmitted infections)

• Counselling
• Health Education
• Management of uncomplicated STIs

Mental Health

• Psychosomatic illnesses
• Insomnia
• Other illnesses as may be listed from time to time by the NHIS

viii. Paediatrics

• Feeding problems and nutritional services
• Treatment of common childhood illnesses, e.g., (malaria, other febrile illnesses, vomiting and uncomplicated diarrhoeal diseases, uncomplicated malnutrition, failure to thrive, measles, upper respiratory tract infections, uncomplicated pneumonia and other childhood exanthemas, simple skin diseases and viral illnesses)
• Other illnesses as may be listed from time to time by the NHIS

Obstetrics & Gynaecology

• Acute pelvic inflammatory diseases
• Vaginal discharges
• Routine maternity care for all pregnancies (ante-natal, delivery & post-natal) except where complication(s) exist.
• Other illnesses as may be listed from time to time by the NHIS

Note: Postnatal care cover the neonate and preterm/ premature babies for 12 weeks after delivery

Ophthalmology

• Treatment of minor eye ailments including:
• Conjunctivitis
• Simple contusion, abrasions, foreign bodies etc.
• Other illnesses as may be listed from time to time by the NHIS.

Emergency Care

The beneficiary requiring emergency treatment shall visit his primary facility or the nearest NHIS accredited health facility. The Healthcare facility is to offer the following treatments (where applicable) before referral if necessary:

• Establishing an intravenous line
• Establishing patent airway
• Management of convulsion
• Control of bleeding
• Cardiopulmonary resuscitation
• Immobilization of fractures using splints, neck collars, to ease transportation of patients
• Aspiration of mucus plug to clear airways
• Asthmatic Attacks
• Any other procedure that may be lifesaving.

Family Planning Services

This includes family planning education only

Child Welfare Services

• Growth monitoring
• Routine immunization
• Nutritional advice and health education.
• Other services to be included from time to time by the NHIS

Dental Care

Dental care education (preventative and promotive oral care)

SECONDARY HEALTHCARE LEVEL

Surgical Procedures

All other procedures that cannot be handled at the primary level of care can be undertaken at the Secondary level, depending on the complexity and the competence of the facility

personnel, except those conditions requiring tertiary care or on the exclusion list.

Note: Hospital stay in orthopaedic cases is allowed for 6 cumulative weeks and does not in any way foreclose post hospitalization management. The primary healthcare facility of enrolee shall pay per diem for the first 15 cumulative days of hospitalization while the HMO shall pay for the remaining 27 cumulative days per year.

ii. Internal Medicine

• Screening as determined by NHIS
• All other cases that cannot be treated at the Primary level must be promptly referred to a Secondary centre, except those conditions requiring tertiary care or on the exclusion list.

HIV/AIDS

• HIV Screening and Confirmation
• Management of opportunistic infections
• Provision of ART

Paediatrics

All medical and surgical paediatric cases that cannot be handled at the Primary level except those requiring tertiary care or on the exclusion list

Obstetrics and Gynaecology

• Specialist consultation
• Multiple gestation/High risk pregnancies
• Caesarean sections
• All emergency gynaecological procedures
• All Primigravidae (a woman who is pregnant for the first time) and Grand multipara ( a woman who has had more five or more deliveries) shall be managed at the secondary levels of care
• Other procedures that are not on the exclusion list

Ophthalmology

• Refraction, including provision of low priced spectacles and excluding contact lenses
• All ophthalmological cases that cannot be handled at the primary level except those requiring tertiary care or on the exclusion list.

Ear Nose and Throat (ENT)

All E.N.T cases that cannot be handled at the primary except those requiring tertiary care or on the exclusion list.

Dental Health

• Dental check,
• scaling and polishing,
• minor oral surgeries,
• maximum of two root canal treatment,
• replacement of maximum of four dentures
• All dental cases that cannot be handled at the primary level except those requiring tertiary care or on the exclusion list.

Physiotherapy

All procedures except those on the exclusion list. Hospital stay in stroke cases is allowed for 12 cumulative weeks and does not foreclose post hospitalization therapy.

Note: the primary healthcare facility of the enrolee shall pay for bed stay for the first 15 cumulative days of hospitalization while the HMO shall pay for the remaining 69 cumulative days per year

Radiology/Ultra-Sonography

All investigations except those on the exclusion list.

Note: All radiological imaging must be accompanied with its detailed report

NHIS Antenatal Policy

• Services to be provided at Ante-natal care should include at least the following:
• Investigations
• PCV/Haemoglobin estimation (Hb)
• Urinalysis
• Blood grouping
• HIV Screening
• Blood genotype
• Hepatitis B surface Antigen
• USS (at least twice)
• Fasting blood sugar/Random blood sugar

Note: the above services under primary care and are covered by capitation while the rest shall be handled under secondary/tertiary care and the healthcare facility should follow the due referral procedures.

• Routine ANC Drugs
• Immunization
• Maternity (ante-natal, delivery and post-natal) care for every insured enrolee eligible to cover.
• The above services do not in any way relieve the healthcare facility of other obligations to the gravid enrolee in providing necessary health care services.
• All live births eligible to cover will be covered during the post-natal period of twelve (12) weeks from the date of delivery.
• All preterm/premature babies eligible to cover shall be covered for twelve (12) weeks from the date of delivery.

TERTIARY HEALTHCARE LEVEL

Surgical Procedures

All procedures that cannot be handled at the primary and secondary levels of except those conditions on the exclusion list.

Note: Hospital stay in orthopaedic cases is allowed for 6 cumulative weeks and does not in any way foreclose post hospitalization management. The primary healthcare facility of enrolee shall pay per diem for the first 15 cumulative days of hospitalization while the HMO shall pay for the remaining 27 cumulative days per year.

Internal Medicine

• Screening as determined by NHIS
• All other cases that cannot be treated at the Primary and secondary levels of care except those conditions on the exclusion list.

iii. HIV/AIDS

Management of complications of HIV/AIDS

iv. Paediatrics

All medical and surgical paediatric cases that cannot be handled at the Primary level and secondary levels of care except those conditions on the exclusion list

v. Obstetrics and Gynaecology

All Obstetric and Gynaecological cases that cannot be handled at the primary and secondary levels of care except those conditions on the exclusion list 15

vi. Ophthalmology

All ophthalmological cases that cannot be handled at the primary and secondary levels of care except those on the exclusion list.

vii. Ear Nose and Throat (ENT)

All E.N.T cases that cannot be handled at the primary and secondary levels of care except those on the exclusion list.

viii. Radiology/Ultra-Sonography

All radiological procedures/investigations cases that cannot be handled at the secondary level of care except those conditions on the exclusion list

NOTE: All radiological imaging must be accompanied with its detailed report

EXCLUSION FOR FSSHIP

The following conditions are excluded from the benefits package of the NHIS:

TOTAL EXCLUSIONS

• Occupational/industrial injuries to the extent covered under the Workmen Compensation Act.
• Injuries resulting from:
• Natural disasters, e.g. earthquakes, landslides.
• Conflicts, social unrest, riots, wars.
• Epidemics
• Family planning commodities, including condoms. (this is not covered by the NHIS however other agencies or NGOs may provide these free of charge).
• Injuries arising from extreme sports, e.g. car racing, horse racing, polo, mountaineering, boxing, wrestling, etc
• Drug abuse/addiction
• Domiciliary visit
• Surgery
• Mammoplasty

Ophthalmology

Provision of contact lens.

Medicine

Anti-tuberculosis drugs

Paediatrics

Treatment of congenital abnormalities requiring advanced surgical procedures e.g. TOF, ASD, VSD.

Obstetrics & Gynaecology

Artificial insemination, including IVF and ICSI

Dental Care

• Crowns and bridges
• Bleaching
• Implants

Pathology

Post mortem examination

PARTIAL EXCLUSIONS

• High technology investigations e.g. CT scan, MRI: the HMO would pay 50% of cost.
• Dialysis for acute renal failure (max. 6 sessions)

REFERRALS

 Levels of Referral

Entry into the Programme is via the Primary Healthcare Facility. At that level, treatment is administered as recommended by the guidelines. Cases that require Specialized attention are referred following the laid down guidelines from the Primary to Secondary and tertiary levels. Most tertiary health facilities in the country have NHIS outpatient clinics which provide primary care. These clinics are manned by family physicians. Patients are referred to specialised clinics in the same facility to access secondary or tertiary care as the need arises.

HOSPITALIZATION

Enrolees in the NHIS are entitled to 21 cumulative day’s hospitalization in standard wards with the exclusion of meals. The costs for the first 15 days shall be borne by the Primary Healthcare Facilities while the remaining 6 days shall be borne by the HMO.

In cases of stroke and orthopaedics, the enrolee is entitled to hospitalization in a standard ward for 6 cumulative weeks. The cost shall be borne by the HMO. The primary facility of enrolee shall pay per diem for the first 15 cumulative days of hospitalization while the HMO shall pay for the remaining 27 cumulative days per year.

How to register for the National Health Insurance Scheme (NHIS)

INFORMAL SECTOR SOCIAL HEALTH INSURANCE PROGRAMMES

Group, Individual, Family-Based Social Health Insurance Programmes (GIFSHIP): This program has the same benefit packages as to the Formal sector program. Visit our GIFSHIP page to find out how to register.

National Health Insurance Scheme (NHIS) PDF

You can view the pdf version of the national health insurance scheme.

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