Implementation of National Health Insurance Scheme

The National Health Insurance Scheme runs under the management of the National Health Insurance Management Authority which is widely referred to in its short form as NHIMA. NHIMA commenced the implementation of the National Health Insurance Scheme (NHIS) on 1st October 2019. Its primary objective is provision of access to quality essential health-care access to its citizens, as its motto says – ‘Leave no one behind’. NHIS applies to all Zambians and established residents in the country. The contributors will benefit as well as all registered members of the contributors’ household – spouse, biological and adopted children, and other eligible dependents will be covered and entitled to insured healthcare benefits

Objectives of NHIS

  • To ensure that every Zambian has access to good health care services.
  • To protect families from the financial hardship of huge medical bills.
  • To limit the rise in the cost of health care services.
  • To ensure equitable distribution of health care costs among different income groups.
  • To maintain high standards of health care delivery services within the Scheme.
  • To ensure efficiency in health care services.
  • To improve and harness private sector participation in the provision of health care services.
  • To ensure equitable distribution of health facilities between rural and urban communities .
  • To ensure appropriate patronage of all levels of health care.
  • To ensure the availability of funds to the health sector for improved services.

Contribution to NHIS

All Zambians and established residents of Zambia are liable by the NHI Act to contribute to the NHIS fund. Employees from both the informal and formal sectors according to their
ability to pay

  • Employers will part contribute for their employees and remit contributions to the Authority
  • Government will continue to subsidize for the poor and vulnerable
National Health Insurance Scheme in Zambia - Contribution Rates

Registration Process for the National Health Insurance Scheme (NHIS)

The National Health Insurance Management Authority is established pursuant to section 4 of the National Health Insurance Act No. 2 of 2018. The main objective of the Authority is to implement and operate the National Health Insurance Scheme, manage the National Health Insurance Fund, accredit health insurance healthcare providers, develop a comprehensive benefits package to be accessed by members, register & issue membership cards to members and facilitate member access to quality health service Thus, for purpose of implementation of the Act, the National Health Insurance (General) Regulations No. 63 of 2019 was issued. The Act provides for the manner of registration of a citizen or established resident into the scheme and the requirements a citizen or established resident should satisfy before being registered as a member of the scheme. The Act provides for three ways in which a citizen or established resident can be registered as a member of the scheme with the Authority, these being:

  • Employer Registration.

  • Pension Manager Registration.

  • Self Registration.

Benefits of NHIS:

The NHIMA Benefit Package is a list of medical services and procedures that the National Health Insurance Management Authority offers to its esteemed beneficiaries of the scheme. The scheme is a family cover but the benefits are per insured individual. However, there is a limit of 3 outpatient visits per health event at Secondary and tertiary level Hospitals unless its a chronic condition.

1. OPD Registration and Consultation:

The scheme pays for registration fees as well consultation fees. These amounts are part of the predetermined capitation and DRGs fees. It provides for the costs of Investigations and Diagnostic tests as per the Investigation List in the benefits Package. This includes radiological investigation such as XRay, CT scan, MRI, Ultra sound and Mammogram.

2. Pharmaceuticals and Blood Products:

It covers for the costs of medicines prescribed in generic names and medical consumables as per the National Essential Medicines List. It includes a medicine list recommended from time to time to meet members evolving needs. The benefit package provides for whole blood where indicated as part of the treatment protocol.

3. Surgical Services

The scheme covers for the cost of minor, major, orthopedic, ENT and diagnostic surgical procedures. The tariff for surgical procedures will include the cost for anesthesia disposables; medicines and
medical consumables, dressing, Orthopedic implants and other medical expendables used during the operation. /

4. Maternal, New-born and Pediatric Services

This benefit pays for cost of deliveries both normal and caesarean, obstetric and gynecological interventions, Newborn and pediatric services as listed in the package. /

5. Inpatient Care Services

This benefit pays for the costs of daily patient admission in private or ordinary ward, Intensive Care Unit, High Dependent Unit, Services for the daily admission costs depending on the level of the facility and the agreed daily rates as per the tariff schemes.
Investigations, Nursing care, Oxygen therapy, Medicines and Medical Consumables dispensed while the member is admitted. /

6. Vision Care and Spectacles

TThis benefit pays for visual corrective spectacles to the member once for every three years as well as vision care services for interventions for conditions such as Cataract, Glaucoma and trauma./

7. Physiotherapy and Rehabilitation Services

This benefit pays for cost of physiotherapy and rehabilitation services offered as in-patient and out-patient. /

8. .Dental and Oral Health Services

This benefit pays for oral health services for both inpatient and outpatient. This includes dental conservation surgeries (e.g. dental filling), gum diseases, dental extractions, braces, dentures and root canal treatment

9. Mental Health

The mental health benefit pays for the cost of chronic conditions such as schizophrenia and affective
disorders such as Mania and depression and other conditions as the NHIS will determine from time to time.

10. Cancer / Oncology services

A limited number of investigations and interventions have been included for cervical, prostate, breast and Colon cancer

11. Medical/Orthopedic Appliances and Prosthesis

This benefit pays for supportive orthopedic and medical appliances such as crutches, hearing aids, surgical pins, plates and screws.

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