‘Mandatory state-supported social health insurance, others to boost coverage’

The National Health Insurance Scheme (NHIS) has been in the news in the recent past, but for the wrong reasons. From the power tussle between the management and the labour union to the near failure of the novel national mobile health insurance programme, and accusations and counter accusations between the enrollees and health care providers on one side, and the Health Maintenance Organisations and NHIS on the other. These imbroglios have almost grounded the scheme, with the mandate to provide universal health coverage for all Nigerians, to a halt. Dr. Femi Akingbade is the Acting Executive Secretary of NHIS. Akingbade was appointed on April 28, 2015, by the immediate past President, Goodluck Jonathan, to steady the ship of NHIS after swimming through troubled waters. Akingbade told journalists how the scheme overcame and is still determined to reach over 30 per cent of Nigerians by December 2015 with the adoption of new but streamlined three major strategies including ‘mandatory’ state-supported social health insurance scheme, public primary schools social health insurance scheme, and a comprehensive and holistic reviewed national mobile health insurance programme. CHUKWUMA MUANYA writes. Excerpts: 

The NHIS has been in the news in recent times for the wrong reasons especially concerning the tussle between the management and staff, and the impromptu removal of the former Executive Secretary? What is the situation now? In fact I actually took responsibility of the headship of the National Health Insurance Scheme (NHIS) on April 28, 2015, and as that time we had a lot of programmes that were lined up as initiatives to move the scheme forward in terms of stability in the scheme. I think for almost a year now we have some form of stagnancy.

Though we have been trying to develop all these programmes but the attitudinal nature of the staff was not allowing a lot of things to move forward so we had so much kind of disagreement between management and the labour union, we had a court case in court.

But by and large, as at that time coverage was hovering around seven million in terms of total coverage we had in the scheme then. By and large, the operations were not moving as desired. However, now we have had relative stability in the scheme.

One of the things that has actually been disturbing the scheme all these while has actually been the imbroglio as I said between the management and the labour union on the issue of filling up vacant positions that we had in the scheme as at that time.

Currently we have been able to surpass that, we have been able to elevate those that are qualified that are Deputy General managers, 15 of them have been promoted to General Managers and this actually gives a lot of hope to other upcoming staff that they can actually get to the peak of their career also.

So this has brought a relative peace to the organization and created a conducive environment for the scheme to move forward. In terms of our programmes, we have actually streamlined the programmes we have to be those that can actually help us in achieving the universal health coverage, which is the main goal of the scheme for now.

We have reviewed a lot of programmes that we are embarking on and try to zero down to maybe like two or three of them that can actually give us that critical mass that we are talking about. One of them is the State supported social health insurance programme. We also have the public primary school social health insurance scheme that we are planning and also a comprehensive and holistic review of the national mobile health insurance programme.

Those three programmes are three programmes that we think can actually aid in the generation of the critical mass that we are talking about towards the attainment of universal health coverage (UHC). Talking about UHC, the NHIS and the National Primary Healthcare Development Agency (NPHCDA) are key.

So what do you intend to do differently so that we can attain that status? Well like I said before one of the problems we have always had with health insurance before has been this lacuna of saying that health is on the concurrent list and what that directly implies is that the federal government can actually give pronouncement from the centre but the states are not compelled to follow them and that has actually brought a gap in what we are talking about because you find out that a lot of states are not keying in either because of political reasons or other agendas that they have at the state level.

So non-participation of the states has always been a problem of health insurance because of non-compulsory or non-mandatory nature of health insurance in Nigeria.

So that has actually been a problem. As you asked what are we going to do differently? What we are going to do differently is to be able to now go to the states and now give them autonomy.

We are now decentralizing the operations of the NHIS down to the state level. Towards this we have also created states offices to be able to manage all these states initiatives and give the states the autonomy to be able to run their own health insurance agencies at the state level. This gives them a sense of ownership because one of the skepticism is how do I bring my money to the centre.

But now we are saying keep your money in your states, run your agencies, man it with your own people and we also give you a perk to it by adding a counterpart funding to whatever funds that you provide at the states. We are expecting some of these funds to actually come from our gains and also from the National Health Act where one per cent was seeded for us from the consolidated revenue.

We understand that the NHIS Bill is still pending at the National Assembly, now this aspect of decentralizing the scheme to the states is not going to meet a brick wall? There are two things, which I don’t want you to mix up. There is the National Health Act and there is the NHIS Bill that is still ongoing.

The National Health Insurance Act has been passed and even signed by Mr. President. Now the NHIS Bill, we actually have two versions of it.

One was at the House of Representative and the other one at the Senate. The one that was passed now that is awaiting the signature of Mr. President was the one that comes from the House of Reps, which we have reviewed by submitting another one to the Senate.

So one of the things we are doing at the NHIS now is to make sure that the Bill does not pass the President’s signature. So we have made representations to Presidency to say that the contents of that Bill that is being passed is not what we want.

But I understand that part of what was contained in the NHIS Bill that is awaiting passage is to make health insurance mandatory? Yes it is actually in the Bill and that was actually incorporated into this one but there are other areas of it, which are not going to be favourable for health insurance in Nigeria and that are why we reviewed it earlier on and passed it to the Senate.

We expected that one was the one that would have been passed and not this one. So what is the difference between the National Health Insurance Act and the NHIS Bill? The National Health Act actually takes care of the whole country but the National Health Insurance Bill actually just states how the NHIS should be run.

So in terms of making the states to be autonomous, what concrete states are you taking? Are coming up with a legislation to make them agencies or what? One of the things we first did to make it work was to form a technical working group, which comprises all the stakeholders in the health sector- the Health Maintenance Organisations (HMOs), the Health Care Providers of Nigeria (HCPN), the NHIS, legal luminaries, States representatives of health and all stakeholders that we actually think that will be important. So we set up the technical working group to actually look at two things.

One was actually to be able to draw up a draft Blueprint for the operations of States supported health insurance programme and then the second one was to draw up a kind of legal framework that can actually be adapted and tweet based on the need of each state. So what we have just done was to create just like a zero template that every state can actually start with and then based on the peculiarity of each state they can actually modify or add or take off from what we have developed.

So we have actually been able to take been step forward to assist them. So instead of them wasting time developing a Blueprint, developing a legal framework, we already have a zero template, which we are ready to give to them. They can actually start with this by taking it to their House of Assemblies and pass the law. Some state governments have taken a cue from that. Lagos state has actually passed their own law which was signed at the tail end of last administration of Governor Fashola and I think they are about the only state that have signed now. But we have other states that have actually keyed in such as Delta, Kaduna, Ogun and some others have gone a long way in making sure that these laws are passed in their states.

There was a lot of excitement when the national mobile health insurance scheme (NMHIS) was launched but as it is now, it is having a lot of hiccups. What is the situation and what are you going to do about it? Like I said, we actually looked at all our programmes and we are trying as much as possible to review them for optimal delivery of service to the populace.

The NMHIP was actually launched July 2014. It is a very laudable programme. It is a programme we would like to upscale to the highest level. We actually see a lot of interoperability of that programme with so many other things that we run and also require collaboration with a lot of other agencies.

We need to collaborate with National Communications Commission (NCC), we need to collaborate with the National Identity Management Corporation (NIMC), Mobile Network Operators (MNOs), with a lot of other agencies that are into identity management and that has actually slowed the process down. We are actually working on it because one of the things we wanted to do with the NMHIP was to leverage on existing teledensity of the MNOs.

They already have about 120 million people registered under them and the idea of NMHIP was for you to be able to link you telephone number with existing data that was captured during SIM registration with the MNOs. Coincidentally the data base is being warehoused by the NCC and one of the things we are trying to work on and implore NCC to do is to be able to release that data base for us for access to be able to get to that data.

This actually saves us a lot in recreating the will. They have already done biometric registration, they have the photographs, fingerprints, the details of the people that own these lines.

So what we are saying is that if somebody that owns a phone wants to register for NMHIP please avail me the data so that I don’t need to go ahead and start capturing new fingerprints, new photographs, which is exactly the same collaboration that we are trying to work with National Identification Management Corporation (NIMSY) on the harmonization of the two data bases and also we want to use the opportunity to help NIMSY to register people.

How about people that have already registered with the NMHIP by following the instructions of the mobile networks? Now that is the other side because we are trying to bring the stakeholders to the same page with us because one of the things that are happening now is that we are having service delivery failure because the stakeholders seem not to totally agreed with the payments and the fees that are coming to them based on the agreed distribution of the funds that are being contributed.

These can be attributed to a lot of things because we found out that the MNOs are involved, there are a lot of government charges they have to pay and a lot of the fees are going into administrative charges which we are trying to reduce and that is why we have not been able to provide the optimal services for these enrollees. But like I said we are reviewing the whole programme and I am sure that very soon we will be back on track and people will be able to access service.

For now one of the things we have promised those that are registered is that if you go to any hospital, NHIS will reimburse the hospitals directly. We have started the pilot run in Lagos and we identified 20 facilities for that purpose, which we have met and agreed with those that if any of these patients come to them, we will reimburse them directly.

I think the problem is that because of the spread of those 20 facilities, some people see the distance from their location as still being far and therefore they have not actually gone ahead to patronize those people. I am sure that with time. We are actually trying to do a national launch so that all accredited facilities under NHIS will be available for service in the nearest future.

There is still this challenge of persistent complain from enrollees as regards to poor services from their health care providers. How do you intend to address that? Well we have tried to strengthen our standard and quality assurance units by doing spot checks on all these facilities and now we are playing our regulatory role very well and one of the things we are bringing out so strongly is that erring HMOs will now actually have to be sanctioned.

We have criteria for sanctions in our operational guidelines and I think we have had cases of two or three of these facilities that have been sanctioned. One of the things we also did last year was to reaccredit the HMOs, which actually reduced the number from 78 to 60. 18 of them were not reaccredited and we actually have all this information on our website. People can actually go to our website and check accredited HMOs.

So we will continue this process. We have sectionalized the facilities into regions and on the regional level we are also checking these facilities to make sure they are in conformity with the standards we have laid down in our operational guidelines.

Another begging issue is that of capitation. Some HMOs allege late payment of capitation and the arrears. Such situation will naturally disrupt the smooth running of the scheme. What are your plans to tackle this? I don’t think that there is any HMO that can say that NHIS has defaulted on the issue of payment of quarterly capitations and fee for service because for one we payments three months upfront and quarterly.

They in turn now pay the facilities. We have had cases of default from HMO to facilities where facilities have actually complained that HMOs are not paying them on time because the HMOs are now expected to pay them on monthly bases. We have had cases of that happening and as I said we had cases of also sanctioning some of these HMOs for late payment. However, there was a review that was done in 2012 for capitation and fee for service. Capitation side of it was effected immediately and them the fee for service was not effected immediately.

We are actually making plans now to pay the outstanding amounts for the fee for service side so that we will not have any case of service delivery failures. The HMOs are actually taking a risk at that secondary level and we have actually reviewed the cost of those services in 2012 but we have actually making preparations to actually pay the outstanding and implement the new rate for fee for service.

So I don’t expect any default from that side henceforth. The HCPN is having some misgivings on some of these new measures. What is your relationship with them? They are the main provider of service so I would not want to say they are the most important stakeholders but they really are because they are the ones that deliver service to even the enrollees that are being generated.

I think one of the things that is always a problem, like I said, are these issues like primary care, secondary care and tertiary care. You see a lot of hospitals getting registered at the three levels of care. They register as primary, secondary and tertiary provider.

This has not made the spread to be equitable. So you find out that those that are big and well muscled because they provide those services at all these levels a lot of people tend towards them and that actually takes away a lot of funds that would have actually gone into the private sector for the development of the small cottage hospital, for the small primary health care centres and things like that. So one of the things that we are trying to look at now is how to streamline it. If you registered for primary service your offer that and if you are registered for secondary service you offer secondary service.

This actually gives a true flow so that in every health care delivery should start from a basic primary level and then the referral system can actually work better and you will see that a lot of the big health facilities will be decongested and will not be overstretched.

How far with the Maternal and Child Health (MNCH) projects established in the states? Well the MNCH programme is tied to the Millennium Development Goal (MDG) programme because it is part of the MDGs that we are supposed to achieve. We have had good success.

Till date we have actually treated about 1.9 million people under that programme. For now it is winding up, the MDG programme is winding up but we are not backing out because in the National Health Act it actually makes it mandatory for us to provide health services for those that can be classified as either poor and vulnerable and if you are talking about people who are vulnerable then pregnant women and children under five are.

So NHIS will still continue this programme but maybe in a different way but we will still take care of children under five and pregnant women. How is it funded? Initially it was funded from a global fund that is being provided by the MDG programme but henceforth it is going to be funded from the National Health Act part of the money that is coming to us.

Like I said the MDG programme initially the way it runs is this: a state is asked to come up with the counterpart fund, which initially when we started was N160 million and then later we increased it to N250 million.

We have about 14 states that are participating for now. So what we do is that if you come up with your own amount of money, we match that fund equally. So if you give us a N100 million, we give you another N100 million and then capitation is paid from it until the money is depleted. As I said we have some very good states that have participated and they have actually enjoyed resources from this avenue. So much has been said about the performance of Ekiti state.

What actually happened? Ekiti state is a good example because we actually saw some things recently that said we are paying some states MDGs monies when they did not pay counterpart funding. Ekiti state actually paid 80 million in January 2014 as their counterpart funding and NHIS added N80 million to it, that is just an hypothetical example.

Till date based on the capitation that has been paid for all the enrollees, we have paid about N143 million to this state and they still have about N17 million left in their buffer. We are expecting that with this new administration in their budget they will be able to come up with more counterpart funding. We have had from Borno State, which has been one of the very heavy paying states that we have had in recent past. They have come up with N250 million on different occasion. Jigawa state has always made provisions in their budget, Yobe, Oyo state although it might be minimal. States like these have actually contributed to the MDG programme and they benefitted from it. Ondo State is a state that has benefitted immensely from it through the Abiye programme, which is majorly funded also from the MDG programme because we have given them a lot of money since they started.

The main target is to get more Nigerians into the scheme. You also set a target of getting to a least 30 per cent universal coverage by December 2015. Are you on course? I will say that the programmes that we are drawing up now are putting us on course to be able to achieve it because like I said if the states can actually make it mandatory.

Just imagine Lagos making it mandatory for residents and citizens of Lagos State, that alone give us about 12 to 13 per cent of total population of Nigeria, which is a large chunk of figure. Currently we are moving towards that, our figures have not drastically improved from what we had but we believe that with the state supported social health insurance programme, once also these states can actually make it mandatory we will achieve or even surpass this 30 per cent mandate that we were given by the federal government.

Put in figures, as at today how many Nigerians are on the scheme? You see we have a lot of programmes that are running but if I work with the figure that is in my own database under my own control, I will be saying that we have about seven million enrollees now. What is your target by the end of this year? By the end of this year, like I said we have a presidential mandate of 30 per cent, which if you actually calculate 30 per cent of 160 million, you will be getting very close to 50 and 45 million Nigerians. So we are looking at that and we are praying and hoping that we will achieve that. Give or take, maybe a quarter into next year even if we don’t make it by December 2015.