Helping NHIS to achieve universal health coverage

Stakeholders believe that the Health Maintenance Organisations (HMOs) have the knowledge base to help reposition the National Health Insurance Scheme (NHIS) towards achieving Universal Health Coverage (UHC).

Until now, several studies have shown that the NHIS has failed in meeting its mandate of providing UHC for all Nigerians as only about four per cent of Nigerians have a kind of health insurance.

The NHIS and the HMOs have in recent times been trading blames on who is responsible for the failure of the scheme.

However, The Guardian gathered that since 2005 when the public sector social health insurance programme was launched by the federal government for the federal civil servants, quite a number of the accredited HMOs embarked on series of research activities and developed several customized health care bouquet specifically to expand the coverage of the health insurance programme in order to achieve UHC for the country.

Available facts revealed that Ultimate Health Management Services Limited developed the Tertiary Institution Social Health Insurance Programme (TISHIP) for the extension of health insurance programme to all the students in the tertiary institutions across the country. This health care product was developed to capture over 25 million Nigerian youths that are in well over 300 federal, states and privately owned tertiary institutions in the country.

Also, members of Health and Managed Care Association of Nigeria (HMCAN) developed the Voluntary Contributors Social Health Insurance Programme (VCSHIP) for the NHIS endorsement and enforcement in order to organize and pull members of the informal sector unto the health insurance programme utilising the platform of various trade associations and groups.

But The Guardian investigation revealed that all that was required from the NHIS was strong enforcement through collaboration with relevant federal and state ministries, departments and agencies.

In furtherance to this health care bouquet are other products from Ultimate Health Management Services like the customized product for the private schools across the country, the customized product for the construction industry, private guards industry, and others.

Stakeholders led by the Chairman, HMCAN, Dr. Kolawole Owoka, said that the way forward was the urgent need for the new Executive Secretary (E.S.) of NHIS, Prof. Usman Yusuf, to set up the technical committee comprising the representatives of NHIS, HMOs, healthcare providers and the enrollee as promised by the new ES in Kaduna during the NHIS organized retreat.

They said that the ES might also need to repeat his visit to the NLC to discuss the commencement of the required five percent contributions of the federal civil servants to the ten percent contribution from the federal government.

Owoka told The Guardian: “The ES may wish to note that the NHIS was established by an Act which clearly defined individual stakeholder with individual responsibilities and should appreciate and endeavor to work within the confines of the law.

“We all know that health insurance globally is operated on population based payments system whereby the healthcare providers bear the risk at the primary level of care and accredited health maintenance organizations bearing the risk at the secondary level with standard process and procedure put in place to minimize abuse and fraud.

“With strong regulations by the NHIS and strong collaboration with the health maintenance organizations and the health care providers by the new ES, the health insurance program in Nigeria would certainly witness astronomical growth within a very short time.”

Owoka in a paper titled “Repositioning the National Health Insurance Scheme (NHIS) Towards Achieving Universal Health Coverage (UHC): The HMOs Perspective,” said one cardinal reason why health insurance has stood the test of time in Nigeria is as a result of the Public- Private-Partnership (PPP) model, which has brought in efficiencies and greatly reduced collusion in the system.

He said the HMOs act as fund managers- collection of contributions, payment of capitations and other medical bills for services rendered by Health Care Providers (HCPs)- and the law does not permit the regulator (NHIS) to make direct payments to HCPs.

Owoka said functions of the HMOs include: Provider and member management and education; preauthorization of secondary and tertiary care; provision of risk management strategies to prevent market failure; provision of 24 hour call centre; management of complaint desk to address service issues between members and providers and provision of triage services; and establishment of quality assurance systems to ensure the provision of qualitative healthcare by health care providers.

The medical practitioner said UHC aims to ensure that everyone, everywhere, can access quality health services without facing financial hardship as a result.

He explained: “Every year 100 million people are pushed into poverty and 150 million people globally suffer financial catastrophe annually because of out-of- pocket expenditure on health services.”

Owoka said the goals of HMCAN is to achieve UHC through: the elimination of gaps in population coverage; increase the scope of healthcare services rendered; increase prepayments; ensuring that out-of-pocket payments (OOPP) for health care become less than 30 per cent of Total Health Expenditure (THE) (currently OOPP is 65 per cent); and significant increase in budgetary allocation to health beyond current levels of five per cent of Gross Domestic Product (GDP).

He said HMCAN plans to review and improve the operational efficiency of VCSHIP to enable rapid growth of enrolment. “Currently HMOs are able to sell, but NHIS unable to implement. HMOs round up enrollees, but NHIS unable to onboard the enrollees. HMOs should be allowed to register and produce ID cards. The old method of pre-purchase of VCSHIP vouchers and registration machines has failed. HMOs should be enabled to sell VCSHIP along side their private health plans,” Owoka said.

The HMCAN boss said within 12 months about 3.4 million Nigerians can be enrolled into VCSHIP; and reviewing and improving the operational efficiency of TISHIP to achieve enhanced coverage of the captive 25 million population. He said the challenges under TISHIP are quite enormous such as the change of the guidelines and using one size fits all approach.

Owoka said the new structure of funds management introduced by the NHIS contravenes the NHIS Act and defeats the objectives of the TISHIP as it was conceived and designed by HMCAN members to expand the coverage.

The HMCAN boss wants the NHIS to revisit the commercials and the operational model of the national mobile health insurance plan (NMHIP) to ensure that at least 70 per cent of the premium is devoted to service provision; and any outstanding medical bills settled appropriately.

He also recommended endorsement and activation of new products developed by HMOs, example private schools health insurance scheme, private guards health insurance scheme, construction workers health insurance scheme, product specifically designed for Fulani herdsmen, Community Based Health Insurance Scheme (CBHIS) with a mobile Primary Healthcare Centre (PHC) and an independent veterinary outreach programme, among others.

Owoka also recommended: NHIS to enhance its regulatory capacity to ensure compliance by all stakeholders; cascading the PPP model and the Population Based Payment mechanism into the state supported health insurance across the country for accountability, sustainability and good governance, example CBHI; review of existing laws to make health insurance compulsory; investment in common Information Communication Technology (ICT) platform to interface with the HMOs and HCPs and capacity building to ensure global best practices in regulation; innovative means of funding to provide coverage for the vulnerable groups – pregnant women and children under-five, elderly, retirees, physically challenged persons, prisoners.

HMCAN also recommended: sin taxes for tobacco, alcohol, and son; taxes of goods of ostentation (luxury cars, exotic properties); telecom tax –one per cent of every airtime recharged; government to allocate 10-20 per cent of Value Added Tax (VAT) to health insurance coverage and this should be ring fenced to be used to pay for premium for the vulnerable example the Mexico (Seguro Populare) and the American medicare/Medicaid models; investment in means testing of the target population for health insurance.