In this conclusion of a two-part story, Percy Ani writes about how exclusion of mental illness in health insurance policies compounds travails of mental health patients in Nigeria
When Bayo Ogunsanwo gained admission to study Chemistry at one of the prestigious federal universities in South-West Nigeria, there were no fears as to whether he would succeed or not.
He had always been an outstanding student right from his primary school days, representing his secondary school at various local and national competitions. In fact, there were expectations that he could graduate with a first class.
But in his final year at the university, before he completed his project, 26-year-old Ogunsanwo fell ill and was hospitalised for over a month.
“I was diagnosed with a ruptured appendix. I might have died if I had not been rushed to a nearby hospital by my roommate,” he said, his voice laden with agony.
“An operation had to be carried out immediately and it was recommended I rest for a few weeks to convalesce. What this meant was that I could not graduate and had to stay back in school for another year to complete my project,” Ogunsanwo remarked dejectedly.
Seeing his former course mates in 2018 dressed in the National Youth Service Corps uniforms and posting their pictures marked his journey into depression. He became desolate and skipped meals on several occasions.
“I had never failed at anything in life, and I did not know how to cope with my present situation,” he said. “Besides, things were tough for my parents and staying an extra year in school meant they had to look for money by all means to pay my fees.”
A few months after he sank into depression, Ogunsanwo attempted to commit suicide and would have succeeded save for a neighbour who heard his cries.
He recounted, “That fateful day, I decided to end it all. I bought a poisonous substance and ingested it. A few minutes after, I was in so much pain that I started screaming. Luckily, a neighbour heard my cries and broke the door. He saw me writhing in pain and vomiting. He quickly rushed me to the nearest hospital.”
After he was discharged from the hospital, doctors advised his parents to seek the help of a psychologist. It was confirmed during his first session with the psychologist that he was suffering from depression and would require therapy sessions.
“The thought that this would cost my parents money made me feel more depressed,” Ogunsanwo told Saturday PUNCH.
Mental health and insurance coverage
According to the American Psychiatric Association, mental illness is a health condition involving changes in emotion, thinking or behaviour or a combination of these. Mental illness is associated with distress and/or problems functioning in social or family activities.
The UN in a report noted that persons with mental and psychosocial disabilities represent a significant proportion of the world’s population. The report estimated that one in four people globally will experience a mental health condition in their lifetime.
Depression and anxiety disorders have been identified as some of the most common mental disorders. The World Health Organisation ranked the former as third in the global burden of disease and projected it would rank first in 2030, followed by suicide among 15-29-year-olds.
The medical cost of mental health problems is immeasurable and can really be daunting, especially in developing countries such as Nigeria where the financial burden of getting proper mental healthcare is high unlike in developed countries, where the burden is significantly mitigated by health insurance.
For instance, Ogunsanwo said an hour of a therapy session he attended cost his parents N30,000, adding that he had two sessions every month.
Even though his parents had a health insurance policy, it was immaterial at that trying time as it did not cover mental health treatment. Many times, they visited the offices of their respective health insurance providers to know why their health policies could not cover their son’s therapy sessions.
“They kept getting the same response that mental health coverage is not within the purview of health insurance policies in Nigeria. There were times they had to borrow to pay for the sessions,” Ogunsanwo lamented.
For Joseph Okpokwu, it was job loss that precipitated him into depression. At the height of the COVID-19 pandemic, he was laid off at an engineering firm in Lagos. His situation was compounded by the need to take care of his wife and their newborn.
Okpokwu said, “I couldn’t have lost my job at a worse time. I just had a child and had to cater for the baby and my wife. But with the loss of my job, I had to manage the meagre resources I had saved up while working. I knew the money wouldn’t last forever, so I had to look for other means. I registered my car with one of the ride-hailing service companies.”
But with the nationwide lockdown imposed by the Federal Government, Okpokwu said his plan of finding an alternative livelihood was halted.
He said, “Even when the lockdown was eased, I still couldn’t get a job and at that time, I was at my wits’ end on how to provide for my family.
“Eventually, things came to a head and I started nursing suicidal thoughts. I knew this was a dangerous trend so I decided to seek help. With the help of a few friends in the medical field, I was able to locate a therapist.
“The money I made from working as a cab driver was not enough to care for my young family and it was difficult getting money to pay for therapy sessions.”
Okpokwu said when he got married two years earlier, he subscribed to a health insurance plan that covered him and his wife. But to his consternation, when he approached the insurance company to foot his medical bills, he was told mental health cases were not covered by the policy.
Okpokwu rued the situation he found himself, saying that despite all the premiums he paid, the company could not come to his rescue.
He said, “I was frustrated. I felt betrayed by the insurance company. I felt they probably should have indicated the areas their health policy couldn’t cover. The only thing that kept me going was the love and understanding of my wife and the joy I felt to be a father. Luckily, I got a job a few months ago and my condition has changed for good.”
Data from the American National Mental Health Services Survey reveal that mental disorders are significantly higher in households with lesser income, low levels of education, or limited employment, thus, giving credence to the widely held belief that these individuals are more vulnerable to mental disorders. Unfortunately, these same factors also limit their access to quality health services.
Save for a few families that can afford to cater for their relatives with mental health challenges, a large percentage of Nigerians are thrown into dire straits – financially and physically – when their loved ones are faced with a mental health condition.
Most developed countries long ago realised the importance of a well-rounded healthcare package by compelling health insurance providers to include mental illnesses in their health.
In the United States, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act requires health insurance companies that offer mental health and substance use disorder benefits to do so in a manner comparable to medical and surgical benefits.
The act is a federal law that generally prevents health insurance issuers from imposing less favourable benefits for mental health cases.
Also, in the United Arab Emirates, according to a revised health plan, basic health cover provided by the government will now include mental health and psychiatry, which were hitherto not included in the basic insurance cover.
This move was largely targeted at availing low-income earners with the opportunity to have access to mental healthcare. The insurance will see psychiatry and mental health inpatients, outpatients, and emergency coverage of up to Dh10,000 (N1,116,000) per annum, with outpatients to get 20 per cent coinsurance payable by the insured per visit.
Acknowledging the paucity of quality healthcare provision for citizens with mental health issues, some developing nations have also passed legislation to cater for such patients.
In 2017, India passed a ‘Mental Healthcare Act’ which incorporates ‘mental illness into health insurance coverage. To further buttress the importance of providing access to mental healthcare, the Insurance Regulatory and Development Authority of India requested all health insurance companies to add mental illness to all regular health insurance coverage. The body further requested that insurance companies must not deny health insurance coverage to policyholders who have used antidepressants or opioids in the past.
Nigeria’s obsolete mental health laws amid absence of insurance cover
According to the World Health Organsation, one in four Nigerians – some 50 million people – are suffering from some sort of mental illness.
Ironically, even with the increasing number of mental health cases in Nigeria, there are no adequate laws and infrastructure to cater for patients with these conditions. Other than the obsolete Lunacy Act of 1958, there are no other mental health laws in Nigeria. The outdated law violates the fundamental human rights of persons with mental health and psychosocial disabilities.
The Lunacy Act uses words like ‘lunatic’ and ‘idiot’ and permits magistrates to order the detention of the mentally ill, including those who attempt suicide or engage in self-harm.
Attempts made by some legislators to amend this act hit a brick wall. In 2019, the Senate held a public hearing on the Mental and Substance Abuse Bill aimed at strengthening budgetary allocations and recovery services for mental health and substance use disorder. The bill was not passed.
Recently, the House of Representatives raised concerns over the rising cases of suicide in the country and urged the Ministry of Health to come up with a national strategy to address mental health challenges. Also, a committee was constituted to review the current mental health laws.
The motion was raised by a member of the House of Representatives from Nasarawa, Gaza Gbefwi. He noted that the country’s dire socioeconomic status contributed chiefly to mental illnesses such as depression and anxiety disorders and were the leading causes of suicide in Nigeria.
He further expressed concerns over the lack of awareness among Nigerians on mental issues, adding that depression was one of the most ignored and misunderstood mental disorders.
Until recently when veteran Nigerian actress, Joke Silva, announced that her husband and veteran actor, Olu Jacobs, was suffering from Lewy Body Dementia, the second most common type of dementia after Alzheimer’s, many Nigerians had no idea what the ailment was.
Aside from the physical strain it places on the sufferers, mental illness exacts a significant amount of financial resources. An average income earner is unable to access the scarce and mostly unaffordable mental health services in the country. In many cases, such individuals turn to traditional healers and sometimes religious clerics for elusive healing.
Also, the allocation of funds by the government especially in the health sector has been abysmal. In the 2021 budget for instance, N547bn was allocated for healthcare which is just about seven per cent of the budget’s total of N13.08trn. This means that with the country’s population hovering around 200 million, only about N2,735 is available to cater to the health needs of each Nigerian if the total fund (N547bn) was released. Unfortunately, over the years, amounts released by the government to ministries, agencies and departments were usually less than the approved budgets.
Also, the seven per cent health budget goes against the ‘Abuja Declaration’ in which African governments agreed in April 2001 to earmark at least 15 per cent of their annual budgets for the health sector.
In addition to the poor funding of the health sector, there is acute shortage of psychiatrists to handle to the mental health issues in Nigeria. According to the Nigerian Medical Association, only about 350 psychiatrists are currently serving 200 million people in the country.
Compared to the United Kingdom with a psychiatrist to population ratio of about 9-25/100,000, Nigeria has a psychiatrist to population ratio of 0.09/100,000. This dismal figure further widens the mental health treatment gap in Nigeria.
Furthermore, most psychiatrists in the country are based in the urban areas, thereby shutting out rural dwellers in need of mental healthcare from medical care.
At an event in October marking the World Mental Health Day, the Nigerian Medical Association Chairman, Kwara State branch, Baba Issa, noted that there are fewer specialists in mental health care, lamenting that mental health is the highest among all health conditions.
“In Kwara State, there are only about 12 psychiatrists with all of them practising in the state capital, Ilorin,” Issa added.
Mental health disorders such as depression, anxiety, schizophrenia, obsessive-compulsive disorder, and bipolar disorder require prescription medications in combination with psychotherapy to provide the best clinical results.
Prescription drugs, residential treatment, psychotherapy, and outpatient mental health treatment make up most of the inordinate costs for mental health treatment in Nigeria. Sadly, with a large number of Nigerians battling mental health challenges amidst privation, it is almost impossible for them to afford the wherewithal to access quality treatment.
According to both Ogunsanwo and Okpokwu, they were required to pay between N30,000 to N50,000 per therapy session, held twice a month. This cost, coupled with the economic downturn in the country, nearly deterred them from continuing their psychotherapy sessions.
Ogunsanwo said during his therapy, he was advised to get medication for his depression and anxiety issues – a suggestion that further drained his parents’ lean purse.
He said, “To purchase these drugs, my parents had to borrow more money from friends and family members. I felt so horrible that they had to go through all that trouble for my sake. My parents kept appealing to their insurance providers to help cover my medical bills, but they declined as they weren’t mandated to do so. Those were some of the darkest days of my life.”
Okpokwu also stated that he developed a sleeping disorder because of depression and needed medication.
“It was unfortunate that my mental health needs were consuming more money than I was spending to care for my family. It was tough surviving that period. I kept telling myself that if I had saved all the money I put into my health insurance plan, it might have helped cushion my financial burden when I needed it the most,” he said.
There is a need to implement efficient mental health interventions that can ensure quick and smooth access to mental healthcare services in Nigeria, hence minimising the effects of untreated mental health disorders.
Worryingly, there is lack of coherent and comprehensive mental health laws and policies in Nigeria. Also, advocacy for mental illness is severely inadequate due to fear of stigmatisation, with no formally recognised national or regional mental health association.
Unlike Nigeria, the Government of Seychelles, working closely with health professionals and advocates, undertook a careful reform process that paid close attention to international human rights standards.
The principles of dignity and quality of life were at the forefront. They ensured that persons living with mental health conditions were part of the law reform process and that their views were heard.
Commenting on the lack of coverage of mental healthcare by insurance providers, Medical Director, Federal Neuro-Psychiatric Hospital, Yaba, Lagos, Oluwayemi Ogun, posited that the government needed to enact laws that ensure mental health problems are captured in insurance policies.
She said, “At the moment, insurance policies in the country do not cover any mental ailment. Including it will serve as a respite for people suffering mental illness. There is a need for adequate resources to cater for people with mental health problems. People are getting poorer each day but with insurance coverage, the financial burden can be lessened.”
Why mental health is excluded from insurance cover – Operators
A representative of one of the leading insurance companies in Nigeria told our correspondent that people with mental health problems are not covered by health insurance because they are ‘high risk’ customers.
The official, who spoke on condition of anonymity because of the sensitive nature of the matter, said insurance companies feared they would likely pay huge claims due to the high cost of treatment.
He said, “Even though health insurance is there to cover the financial health demands of the insured, they (companies) are also in business to make a profit. With mental illness coverage, especially in persons who have a history of mental illness, there is fear that it might arise again.
“No insurance company in Nigeria will accept such customers. The only way to attack this problem is for the government to intervene. Discussions must be had between the government and insurance stakeholders.
“It makes no sense that insurance companies abroad cover mental health ailments but when the same companies come to Nigeria, they refuse to do same. It means the government must create policies and ensure compliance from health insurance providers.”
A broker with another reputable insurance company located in Lagos said health insurance did not necessarily cover pre-existing health conditions.
“If a person has a pre-existing case of panic attacks or depression before taking out an insurance policy, the policy cannot cover such health condition,” the official said.
He added that the government participation in mental health insurance coverage is the easiest way to properly address mental health issues.
The source said, “Even if insurance companies were to cover policyholders with mental health problems, the premium they would be required to pay as high-risk customers would be higher than customers who want the basic health insurance plan.
“The only way this problem can properly be addressed is through government policies and holistic involvement in health insurance. It is what governments in many developed nations have done to ensure that patients with mental health challenges are not disenfranchised from health insurance.”
Commenting on the issue, a Professor of Insurance Management and Finance, Christian Nwike, said the National Insurance Commission that oversees insurance regulations in the country is not doing enough to ensure adequate insurance is provided for Nigerians.
He said, “Health insurance policies in Nigeria do not cover many diseases. Their services are very limited. If you check the health insurance policies of other countries, you can find a myriad of ailments that they provide cover for.
“If these Nigerian insurance companies do not cover all the basic health challenges, then it is no surprise that they do not cover mental health problems and at the moment, mental health is a serious challenge that most countries are already tackling using health insurance.
“The National Health Insurance Scheme introduced in the country is not being run the way it should. Its sole purpose is to provide easy access to healthcare for every Nigerian. But that hasn’t been the case.
“The government needs to carefully look at the health insurance available in the country and what ailments they cover. They must then find out why insurance doesn’t cover diseases that are covered in other nations. It is necessary that insurance is being run at an optimal level.”
According to a legal practitioner, Malachy Ugwummadu, health insurance in Nigeria is at its fledgling stage.
He said, “What we need to do now is pick up some identified cases, put them into a serious campaign, and find a way of incorporating them into the body of policies and laws available in the country through the National Assembly, and by way of amendment.”
Another lawyer, David Akpeji, urged members of the National Assembly to ensure that the requisite mental health bills are passed.
“If they can pass the law that protects the rights of people who suffer mental health challenges, it will not only lessen the burden on these individuals and their families but also create awareness on mental health challenges,” he added.
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