WHY ARE THEY MISMANAGING NHIMA?
Since 2011, the Government of the Republic of Zambia has been trying to start and work on a health scheme that allowed entire population to pool resources into one basket and then procure medical supplies and services for the entire population, for all and one.
In 2018 after extensive research and consultation, the National Health Insurance Act No. 2 of 2018 was enacted into Law. Financial resources of circa K500 million were needed in the 2018/19 budget to start the project, but only K11 million was allocated. This should have dealt a huge blow to the prospects of the scheme taking off in 2019. But when political will, leadership, and management skills are combined, there is nothing that our country can fail to achieve!
It was agreed by the then Minister of Health, Dr. Chitalu Chilufya, that the project can start with the right leadership and skills notwithstanding no budget allocation. The Board of the National Health Insurance Management Authority (NHIMA) was instituted in March 2019 and in June, Mr. James Kapesa, an accountant and investment banker, was appointed director general. Understandably, the scheme was heavily opposed by unions, opposition political parties, and the general citizenry citing other past government projects that failed due to wastefulness and corruption.
Prior to the NHIS, only 4% of Zambians had access to good quality health care through insurance. The rest of the 96% faced financial barriers going to hospitals. For those who had finances, the prospect of poor service, lack of laboratory equipment, and chronic shortages of medicines deterred them. So, we had a 4% island of rich, healthy citizens in an ocean of 96% poor and unwell citizens. This was never going to be sustainable. This was a ticking time bomb!
Under the NHI Act, the NHIS is a social scheme that pools money together from the rich, the middle class, the poor and pay for every member’s medical bills on the basis of their medical needs and NOT their social status. In this way, the well-to-do subsidise the poor, the young and health subsidise the old and feeble.
The broader purpose for the NHIS was to provide complementary health financing to the health system, which had hitherto been chronically underfunded. It was noticed that the quality of health had been deteriorating due to underfunding.
All Zambian citizens and established residents qualify to be members and benefit from the scheme. However, contributing members must be aged 18 years to 65 years. Each contributing member can bring a spouse and five dependents under the age of 18. Those above 65, the mentally challenged, and those on social cash transfer are exempt from contributing but are eligible to access the benefits.
A qualified and active member can present themselves and their family members at an accredited health facility and will access a predetermined health benefit package without paying anything. The health facility will generate a claim and send it to NHIMA, who will pay on behalf of the member who accessed the service.
The medical services covered under the NHIS include consultation, OPD services, admission into wards, minor and major surgery, laboratory services, blood products, medicines and pharmaceuticals, renal and kidney, selected cancer services, mental services, orthopeadic. The package also includes maternal care, internal medicines, and eye, ear, and heart conditions.
NHIMA is now the largest membership parastatal, with over 3.5 million members and dependents registered, of which over a million are in the informal sector.
Nearly 370 health facilities are part of the NHIMA network. They include all government district hospitals, general hospitals, and teaching hospitals. Most of the private hospitals, laboratories, and pharmacies are also part of the network. Where a government hospital has no medicines and laboratory equipment is not working, a member can present at a private pharmacy and laboratory and be attended to. The private pharmacy and laboratory will send the claim to NHIMA for payment.
The inception team under the leadership of Mr. Kapesa designed the financial system of the NHIS on the foundation of efficient private sector banking systems. This enabled NHIMA to start from no funding to a viable vibrant health financing system; the fourth of its nature in Africa and only such in Southern Africa.
From the first collection of only K700,000 in November 2020, NHIMA now collects nearly K100 million monthly.
Over 3 million Zambians have accessed quality health care without paying cash and the journey to universal health coverage where 100% of Zambians are covered now seems possible.
The NHIS has, for the first time, aggregated small fragmented informal sectors contributions and put them into the formal financial system. This has increased formal finances in circulation, further allowing the banking sector to expand.
The private health sector has expanded exponentially in the last 4 years of the NHIS existence and has employed significant numbers of health care workers who hitherto could not be absorbed by public health facilities.
The NHIS has tremendously reduced households out of pocket expenditure as now they don’t have to pay cash at hospitals and / or send money to relatives for medical care, and the relatives are now on NHIS. Prior to NHIS launch, households spent around 12% of their disposable income on out of pocket health costs.
Health coverage has soared from 4% in 2018 and now stands at over 40% in 2023. If supported and properly managed, Universal Health Coverage is attainable in the next 10 years.
NHIS has complemented the Ministry of Health in the last 4 years with much needed health care financing. With erratic procurement of medical supplies, save for NHIS intervention, the health system would have collapsed.
However, since ascension to power, principal officers of the UPND - from State House, Ministry of Finance and other line ministries - have not mentioned NHIS in their policy speeches. This silence portends harm and ill-will towards the NHIS. It is believed that this is due to business interests and conflicts from the leadership of the UPND that has competing business interests with NHIMA’s principal activity.
The move to the Ministry of Labour is another sign of ill-will towards a scheme that focused on Universal Health Coverage. Additionally, the placing of the scheme under the Ministry of Labour is a strategic misaligned that interrupts the synergies that a health scheme gets from a ministry in charge of health. No one was consulted from NHIMA and Ministry of Health when Mr Hichilema's government transferred the scheme in the first week of their ascent to power.
NHIS was designed to complement Government funding to the tune of about 20% of the funding gap. In the last 3 years, there has literally been no meaningful procurement of drugs and medical supplies. This has meant that NHIS became the default supplier of medicines for the entire medical system. This is NOT sustainable and may cripple the scheme into premature insolvency.
The governance and management of the NHIS has also been suboptimal with the Board and Management more focused on travel, workshops, and hounding out original office bearers. As a result, the scheme is nearly insolvent, service disrupted, and now demanding budgetary appropriation instead of generating its own money. For example, the Director General, Mr. Kapesa, was fired on politically trumped up charges that he was illegally employed as he had neither relevant qualifications nor management experience. So far, three of the inception directors who designed the systems have left the scheme. One is leading a similar project in Liberia setting the NHIMA equivalent, and another one is CEO of a large private health insurance company locally. As a result, most management performance indicators have been abandoned. The Board has spent in 18 months more than 10 times that the previous board spent in 36 months in allowances and unending foreign trips.
Owing to sustained erosion of professionalism in the governance, tribalism and chronic, relationship, and compliance management models imbedded in the NHIS at inception have been abandoned. This has led to low compliance levels as no one is enforcing compliance. The result is lower and lower collection of contributions whilst naturally claims are increasing. If there are no drastic changes in the management model, the scheme will implode.
In the medium to long term, the contribution rate of 2% is low and ought to be adjusted upwards to at least 5%. But this should be done after management has done their part in elevating collections through compliance.
Health service levels in public facilities are low and undermine the intentions of the scheme. This has worsened by taking the scheme away from the Ministry of Health. This was the very reason why NHIMA was designed to be under the Ministry of Health.
Unless political will, sober governance, and competent management are introduced, the scheme could be insolvent in the next 2 years, barring the other matters of contributory rate and base.
The NHIS is now the most beneficial and popular projects left by the PF and which has helped UPND in the eyes of the public.
This is a good scheme that shouldn't be allowed to fail. It is a scheme that deserves support and continuous improvement.
We challenge to Mr Hichilema is for him to explain why his government is shunning such a popular people driven scheme? Is it that they want to trade it at the altar of their personal business interests?
The NHIS needs to be strengthened and devolved to rural and peri-urban communities and be properly supported by all government functionaries. The scheme needs to be taken back to the Ministry of Health.
There's a need to protect the investments of the scheme from conflicted third-party players who are in government now and then so that the NHIS expands its resource base to provide health insurance for the foreseeable future.
Fred M'membe
President of the Socialist Party
