‘It is abnormal to paint everybody with one brush’

National Publicity Secretary of the Health and Managed Care Association of Nigeria (HMCAN), an umbrella body of the Health Management Organisations (HMOs) in the country, Dr. Lekan Ewenla, speaks on the role of the HMOs and where there is conflict of interest among the stakeholders

Going by the NHIS Act, what are the roles of the NHIS, as the regulator of the scheme?
The basic responsibility of the NHIS, as an agency of government, was to set and enforce accreditation requirements and quality standard for the other stakeholders- the health maintenance organisations and the health providers. The scheme was designed to make health care affordable, accessible and bridge the gap of accessing care by both the rich and poor. It doesn’t affect the quality of healthcare; it’s all about having access.

Why is there low level of awareness about the scheme?
Part of the responsibilities of the NHIS was to create public awareness on the workings of the scheme, which has not really grown beyond that of the civil servants. The level of awareness is very low, but we, the HMOs, individually organise sensitisation programmes for our enrollees on a quarterly basis.

At the HMCAN level, we equally organise interactive session once in a quarter at each geo-political zone.

If the essence of setting up the scheme was to reduce out of pocket spending, why do healthcare facilities prescribe drugs and ask enrollees to go buy the drugs, under the guise that the drugs are out of stock? 
There are two risk bearers- the healthcare provider will bear the risk at the primary level, a certain amount is paid upfront to them to enable them provide services at the primary level, while the HMOs bear the risk at the secondary level.  A certain amount is equally paid to HMOs to provide secondary and tertiary services with a standard procedure in place. That could be placed on the doorstep of poor awareness and poor knowledge of the workings of the scheme.

The reason the HMOs are there and the reason ID cards are issued to enrollees, including the dependants, is for them to know who their HMO is, so that when they have issues at their facilities, they should be able to call their HMO.

It is not right for any hospital to ask any enrollee to go and procure medication. If the medication is not available, which is the worse case scenario, they will ask you to wait or come back and collect it, because it has been paid for.

Does NHIS cover only little drugs? 
There is nothing like little drugs; NHIS medication is meant to be generic, it doesn’t cover branded drugs, but generic drugs, which efficacy is equally good.

What this means is that, if GSK or Beecham’s should develop a cough syrup based on their findings, they are at liberty to solely produce that medication for a number of years to recoup their investment on their research. Thereafter, they now sell the patent to other pharmaceutical companies across the world and the patent goes with the composition of the medication, so it is not inferior.

That was designed to make medication affordable and accessible. It doesn’t affect the quality of the medication.

What is the role of the HMOs in the NHIS chain? 
Before the introduction of health insurance in this country, if you, as a patient, walk into a hospital and you are treated shabbily, you probably don’t have anybody to report to. But with the introduction of health insurance, the HMOs are the ombudsman, they are there as the health auditor to ensure that quality care is given to you and if there are issues, you call the HMOs and they will rectify it. The HMO will investigate and report to the NHIS. We call it quality assurance.

It is our responsibility to ensure that once you are in the hospital, you are treated like a king and a queen. If there are still cases of facilities treating enrollees like lepers, they should call the HMOs.

What is your reaction to the NHIS Executive Secretary’s allegation of N350billion fraud against HMOs?
We would like him to provide further clarifications on this, because if the understanding of the workings of the scheme is there, he will know that the amount mentioned does not come to the HMOs. The HMOs are meant to pay the hospitals on monthly basis based on the number of enrollees they have. Therefore, NHIS must have been lagging in their regulatory functions for them to be accusing the HMOs of corruption.

It is abnormal to paint everybody with one brush, because we have so many HMOs, so if one or two are found guilty, they should be sanctioned.

It is the responsibility of the NHIS to recommend, who to probe to the ICPC and EFCC. If there is evidence of non-payment, they should do their reports. NHIS, as the regulator, has the powers to sanction. The operational guideline stipulates penalty for infractions.

The NHIS, at the beginning, accredited those hospitals across the country and we have the network of NHIS accredited facilities. When there are enrollees choosing those facilities, it is the responsibility of the HMOs to further establish that one-on-one relationship, because quality assurance service is our responsibility.

NHIS does not pay the hospital directly; they pay the hospital through the HMOs. If I am getting N100million per month, about 90 per cent of the amount, which is about N90million, goes to the hospitals.

In addition to that, on a quarterly basis, the NHIS sends its staff to the HMOs office for reconciliation. If out of N100million, there are few hospitals whose facilities we couldn’t locate due to change of address, and this reflects in the payment schedule, the money would be sent back to the NHIS, because it is not our money.

So, how much have you received? 
The only money that the HMO lives on, like I said earlier, is just five per cent, which is like a commission, like their administration fee and that is per person sum, which is being paid per month.

What could be done to grow the scheme and enable it work effectively, like in other climes? 
The law is there and has stipulated who plays what role. NHIS is the regulator, let NHIS do their work effectively, because the HMOs are the operators of the scheme and we should be allowed to operate the scheme, while the NHIS regulates.

If anybody is found wanting, the penalty is stipulated in the law, because if they work with the laws, there would be systematic and tremendous growth, as the HMOs have the intellectual capacity, infrastructure and financial muscle to grow any insurance scheme.

NHIS has been running down the HMOs and the Federal Government should call the NHIS to order, because the Executive Secretary is running the NHIS like a sole administrator.

A situation whereby he doesn’t understand the workings and he is failing to listen to the critical stakeholders in the industry is a cause for concern.

The Executive Secretary should call the HMOs and if he doesn’t have the knowledge, they will put him through, because they have the knowledge.

I appeal to the National Assembly to use this issue, this misconceptions, misrepresentation and misinterpretation to create a platform to meet with the key stakeholders in the industries, so that they can listen to all the parties- the HMOs, healthcare providers and the NHIS and let’s look at the issues and whatever has gone wrong would be rectified.

The NHIS is in the custody of the funds, so it is like somebody that is in charge of the kitchen, you cook the food, keep the key and the pieces of meat that you give to your children, you said they are stealing the meat.

If you are giving us money and it was not disbursed the way it ought to have been disbursed, identify the HMO and sanction the person, we take exception of painting everybody with one brush. It is not done anywhere.

In a situation where the regulator is playing the role of operator, there is bound to be conflict, and that is the bone of contention on the table.