Making health insurance work in Nigeria

The National Health Insurance Scheme (NHIS) has been shrouded in controversy in recent times making the programme dysfunctional.

The other players, the Health Maintenance Organisations (HMOs) under the umbrella of the Health and Managed Care Association of Nigeria (HMCAN) and the retainer hospitals that provide care under the aegis of Health Care Providers Association (HCPAN), are also enmeshed in fraud allegations leaving the enrollees helpless without accessible and affordable health services they have subscribed for. These intrigues have also restricted the reach of the scheme, which is meant to cover at least 75 per cent of Nigerians to 1.77 per cent (about 3,186,000).

Consequently, the House of Representatives Committee on Health Care Services has instituted a probe even as it held a public hearing penultimate week in Abuja.

However, worried by the situation, medical experts and stakeholders have proffered solutions on how to make the scheme functional and meet its mandate.

Chairman, HMCAN, Dr. Tunde Ladele, urged the House Committee on Health to: do a forensic audit on all HMOs involved in federal coverage; do a forensic audit on NHIS to determine how much comes from the Accountant General office to the NHIS coffers as to determine what percentage N581 billion is not accounted for; and collaborate with Senate Committee on Health to making Health Insurance compulsory.

Managing Director (MD)/Chief Executive Officer (CEO) of a foremost HMO, Ultimate Health Management Services, Lekan Ewenla, called on the Presidency, the National Assembly and the Judiciary to set up a high powered investigative committee to dig deep into the functions of NHIS since inception, re-direct or re-emphasis their statutory function, possibly begin to consider the creation of a separate entity that would anchor the disbursement of the funds. Ewenla said the only way we can grow health insurance and gradually achieve Universal Health Coverage (UHC) is through knowledgeable, objective, committed, innovative and a friendly regulator that would work closely with other stakeholders.

Medical Director of Optimal Specialist Hospital, which is one of a retainer hospitals and healthcare provider, Dr. Celestine Ugochukwu Chukwunenye, the scheme appears to have been designed as a way of paying back the boys that supported the political parties in power and their masters.

The obstetrician and gynaecologist said from the appointment of the Executive Secretaries to the general running of the scheme, inefficiency seems to have been deliberately built into the scheme. He said the original organogram of how to implement the scheme was jettisoned and in its place is the present system which the present Executive Secretary has aptly described as “a monumental fraud worse that the fuel subsidy fraud”.

Chukwunenye recommends a total overhauling of the scheme with a view to re-aligning it with as originally planned, prior to the 2005 launch. He said the
NHIS should act as a disciplined regulator, no more, no less.

He further stated: “It should regulate the HMOs and healthcare providers. The HMOs are to play the intermediary role of sourcing for enrollees at all levels, collecting premiums and disbursing same as agreed to the healthcare providers, HMOs and NHIS. They are not to run any healthcare facilities including hospitals, clinics, pharmacies, laboratories and ambulance services.

“It should be a taboo for any HMO staff to go behind the healthcare provider to discuss the patient’s condition, investigations and treatments with the patient, just because they have been obliged with a summary of the patient’s condition to enable appropriate authorization codes. This is clearly a breech of the doctor-patient relationship.

“The healthcare providers should also limit themselves to the actual provision of qualitative healthcare services to the enrollees. No person should have his name in the list of directors of an HMO and a healthcare provider at the same time.”

Chukwunenye said there is no doubt that there is monumental fraud going on in the scheme but he is not in a position to say the amount. He said one of the ways the fraud is perpetuated is by severely under-pricing some of the secondary healthcare services, such that most secondary healthcare providers would decline to render such services.

Chukwunenye recommends: “Furthermore, in other to solve the problem facing the NHIS as at now, the present NHIS Board and Structure should be converted to a HMO in order for it to account and properly utilize public funds in its confines. Another five to 10 HMOs should be registered to join the NHIS as HMO. Each new HMO should have a capital base of at least N10 billion.

“The present HMOs should be encouraged to merge together to achieve the new status. More HMOs should only be registered when the national coverage is over 40 per cent. This arrangement would reduce the waste of resources on emoluments, accommodation, cars and so on, by the present large number of HMOs, which has greatly affected their ability to pay for the hospital bills of their enrollees from the limited premiums they collect. It would also give them the wherewithal they need to increase the national coverage of health insurance.

“The National Council of States should establish a new Regulatory Agency that reports directly to it. This should discourage the idea of each state government and local government trying to establish its own Health Insurance Scheme and minimise the impact of politics on the Scheme.”

Director General of National Agency for Control of AIDS (NACA), Dr. Sani Aliyu, said the health care delivery coverage must increase significantly, more Nigerians must be enrolled in to the scheme and this can only be done if there is sincerity of purpose especially among the NHIS staff, government at all levels (federal, states and LGAs) and constant engagements with organized private sectors.

Aliyu recommends that Human Immuno-deficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) prevention and treatment services should be covered by the NHIS.

He said: “At this point in Nigeria’s HIV National response, the resources available to fight HIV continues to dwindles as foreign donor agencies are either cutting down or stopping in totality aids to Nigeria. There is the need for the NHIS scheme to become more effective than it is at the moment has it has the capacity to include among the many packages currently offered to patients, HIV prevention, care and treatment services.”

Aliyu said since the cost to treat one patient is known and the cost to run necessary laboratory test is equally known to NACA, efforts are on the way to work in collaboration with NHIS as an agency to work out modalities to include HIV services in NHIS package as this will not only fast forward the realization of the much talked about ownership and sustainability of HIV response in the country.

Meanwhile, according to report by SaharaReporers, penultimate week, the Citizens Action to Take Back Nigeria (CATBAN), a civil society organisation, has exposed rot in the NHIS and called for the arrest and prosecution of Dr. Femi Thomas and Mr. Olufemi Akingbade, former Executive Secretary and Acting Executive Secretary respectively of the of the scheme, who have been the identified masterminds. The group also indicted two former Senate Presidents, Messrs. David Mark, and Anyim Pius Anyim.

The group made its position known in a statement signed on its behalf by Mr. Ibrahim Walan Garba. CATBAN said Thomas should immediately be arrested for unilaterally making illegal payment of N1.05 billion to HMOs and purchase of land at an inflated fee way beyond their budgetary allocation. It made the same demand of Mr. Akingbade, who conspired to use a corrupted database to make dubious payment of N1billion and N50 million to some HMOs.

CATBAN equally called for the identification and prosecution of everyone involved in the theft of funds belonging to hospitals that render services to NHIS enrollees as well as those connected to the fixed deposit accounts in 11 commercial banks at ridiculous interest rates, contrary to the provisions of the Central Bank of Nigeria. The group similarly called for the prosecution of NHIS officials preventing the transfer of funds in commercial banks to the Federal Government’s Treasury Single Account (TSA).