Raging questions, debates over National Health Insurance Scheme

The scheme, National Health Insurance Scheme (NHIS), which promised to cover 70 per cent of Nigerians by 2010, is yet to provide cover for up to two per cent of the population.

In fact, more than 175 million Nigerians still pay out-of-pocket to access health services or rather medical care is inaccessible and unaffordable to most citizens.

Unlike in Nigeria, around the world, NHIS has become an effective tool in financing health care needs of the very vulnerable people in the society. The rich are made to assist the poor by contributing to a pool of funds and the government equally contributes into this pool of funds for affordable health care delivery system.

The NHIS is a body set up under Act 35 of 1999 by the Federal Government of Nigeria, to improve the health of all Nigerians at an affordable cost through various prepayment systems. Nigeria under the former President Olusegun Obasanjo formerly launched the NHIS contributory scheme in 2005.

The many problems of the scheme including fraud allegations and counter fraud allegations between NHIS, the regulator, and 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), was brought to the open penultimate week at a public hearing organised by the House of Representatives Committee on Health Care Services, in Abuja.

It has been alleged that the HMOs despite drawing millions from the government coffers delay payment to hospitals engaged to provide healthcare services to contributors of the scheme, thereby making these hospitals provide inefficient services to patients under NHIS. In some instance, the HMOs and the retainer hospitals connive to inflate numbers of enrollees or amount incurred, all aimed at shortchanging the system, which in turn affect the beneficiaries

The enrollees, you and I, who are supposed to be the major beneficiaries of the scheme in terms of getting quick access to pre-paid quality healthcare at an affordable price, are left at the mercy of middle-men that is the HMOs and retainer hospitals.

The Guardian investigation reveals that most of the enrollees especially those registered outside the federal civil service structure are often treated as lepers.

Indeed, so far the system has worked for some people especially those in the federal and state civil service and selected organised private sector. Testimonies of beneficiaries of the scheme are loud and clear, amongst which is that of a 37 years old civil servant, Adamu Ali, who works in one of the ministries in Abuja.

Adamu who said his wife delivered twice, using NHIS platform and having to pay a token (10 per cent of the total hospital cost after delivery) was full of joy. “This is the first time my country will give me assistance, it was like a dream when I was asked to pay N4,000 from the total N40,000 bill my wife incurred during child birth in a faith based hospital,” he said.

Adamu is one of the few enrollees with positive testimonies about the workings of the NHIS.

Mrs. Adaeze Nnanna has a different story. “When I get to my retainer hospital, I am always treated differently compared to other patients that pay out of pocket. There is always delay in attending to NHIS patients, limited numbers of aliments covered under the scheme, stigma attached to using NHIS as patient are made to form a separate queue away from other patients, bureaucracy involved in getting dependents registered on the scheme and so other limitation being experience in the scheme,” she told The Guardian.

The Guardian also gathered that most of the retainer hospitals has since January this year refused to attend to or treat patients registered under the NHIS scheme, because they have not received any money from the HMO. One of the retainer hospitals in Lagos is in court with one of the HMOs over unpaid fees since 2012; and it said it is considering the court option for others.

The medical director of Optimal Specialist Hospital Gbaja Street Surulere, Lagos, Dr. Ugochukwu Chukwunenye, told The Guardian that over 12 HMOs are presently on suspension of services in the hospital for not paying their fee-for service bills since January 2017.

The Obstetrician and Gynaecologist said they are very uncomfortable with the situation and can see the total collapse of the healthcare system if something is not done urgently to reverse the trend.

Meanwhile, the Federal Ministry of Health said that the continued existence of HMOs in the operation of the NHIS was no longer necessary, following the mismanagement of funds paid to them for effective health delivery in Nigeria.

The ministry said the HMOs had recorded abysmal failure in the health coverage of Nigerians, which has resulted in many avoidable deaths.

Minister of Health, Prof. Isaac Adewole, who was represented by Mr. L H Balami, at the two-day investigative hearing into the “Compliance rate of the Health Management Organisations, HMOs, to the NHIS contributions and utilisation of funds by health care providers and inhumane treatment of enrollees,” said a whopping N351 billion had been expended on the organizations so far without commensurate result.

Suspended Executive Secretary of the NHIS, Prof. Yusuf Usman, said: “For 12 years, the HMOs have never been called to account for their misdeeds… The number of Nigerians covered by the NHIS after 12 years are 1.5 percent of the population. Countries like Kenya and Rwanda have achieved better health care delivery without HMOs and health care financing in Nigeria is nothing but a huge fraud.

“I know all these things because I signed the cheques and nobody has been brought to book in the last 12 years. If you want to hear the truth, hear it from me today, because my way of making the scheme work is to hold the HMOs accountable.

“We gave them N37billion just for administrative fees, patients go to the hospitals and are treated like lepers because the HMOs have not paid the providers. I had to stop it, and they took me to court, Economic and Financial Crimes Commission (EFCC) and Independent Corrupt Practices and Other Related Offences Commission (ICPC), saying that I must be made to reverse back to status quo. What should be the status quo, when you hold on to administrative fees and capitation”? He asked rhetorically.’’

Implementers’ kick
But the HMCAN and HCPAN on the other hand accused the NHIS of not releasing any fund to the HMOs since the beginning of the year. They said the NHIS is supposed to release funds in three months installment ahead to the HMOs for the payment of the health care providers.

The HMCAN and HCPAN said that part of the problem with the scheme is the issue of capitation, which is supposed to be reviewed upwards every two years to address inflation but has only being reviewed once in 2011 since inception. Capitation is a payment arrangement for health care service providers such as physicians or nurse practitioners. They argue that a review from N550 to N750 per patient per month does not reflect the economic and enrollees realities in the country.

According to the implementers of the health insurance programme, each retainer hospital or health care provider is supposed to have at least 5000 enrollees to be able to make headway but some have less than 1000 enrollees. They said most of the enrollees are shepherd by the teaching hospitals and government owned facilities with University College Hospital (UCH) Ibadan, Oyo State and Lagos University Teaching Hospital (LUTH) Idi-Araba having more 20,000 enrollees.

The implementers argue that most of the about 1.5 per cent of Nigerians enrolled under the NHIS are using the teaching and specialist hospitals, which provide tertiary care. This they say negates the principles of health insurance, which stipulate that primary care, should be provided by most of the facilities and specialist centres should serve only as referrals.

HMCAN and HCPAN accused the NHIS of not playing its role as the regulator but rather as a co-implementer, marketer and competitor to the HMOs. They accused the NHIS of warehousing all the funds obtained from the compulsory scheme for all the federal civil servants, where 10 per cent of their basic salary is deducted for health insurance.

Chairman, HMCAN, Dr. Tunde Ladele, disagrees with NHIS boss. Ladele said the accusation of N351 billion, as disbursement to HMOs with nothing to show for it is contentious, spurious and unfounded.

Ladele said if indeed this amount has been paid in 12 years, it simply means premium prepaid after actuarial derivation and negotiation with HMOs and Health Care Providers: no more no less.
However, President of HCPAN, Dr. Umar Oluwole Sanda, blamed both the NHIS and HMOs for the poor performance of the health insurance scheme.

Sanda told The Guardian: “The problem is both with the NHIS and the HMOs. The HMOs get the money and some of them do not pay the retainer hospitals that are the health care providers. But the NHIS has not release any money to the HMOs since the beginning of this year. The NHIS is supposed to release these monies three months upfront to the NHIS to enable them also pay us ahead.

Managing Director (MD)/Chief Executive Officer (CEO) of a foremost HOO, Ultimate Health Management Services, Lekan Ewenla, told The Guardian that it is important to point out that the services at the primary level was properly defined and the generic drugs to be utilised also listed and denominated.

Ewenla said the HMOs are the risk bearer at the secondary and tertiary levels and the services at the two levels were clearly defined and denominated.

He said the HMOs are expected to directly establish contract agreement with the healthcare facilities and regularly ensure that they provide qualitative services at all times.

According to Ewenla, actuarially, the risk based capital framework of the HMOs was actuarially done in order to minimize the loss ratio on fee-for-services rendered at the secondary and tertiary levels and it was generally agreed by all the stakeholders that the civil servants should be allocated to the HMOs on equal number basis.

He said the operational guidelines to ensure the workability of the programme was painstakingly developed with contributions from all stakeholders.

Ewenla further stated: “At the commencement of the programme, the sum of ₦550.00 per person per month was actuarially determined to be adequate and be paid in advance as Capitation for primary healthcare services based on 5000 enrollees, while the sum of ₦89.00 was earmarked to be paid per person per month for secondary and tertiary services to be provided by the HMOs as it was actuarially determined that it is a minimal fraction of the enrollees that would migrate to the secondary and tertiary levels.

“For the HMOs to optimally perform their roles as defined by the law, the sum of ₦91.00 per person per month was actuarially determined to be right as administrative fee for them to provide the required infrastructure, personnel and other necessary working tools.

Ewenla said the most disheartening is the stagnation of the denominated services at the secondary and tertiary levels since 2005 till date as the NHIS has completely jettison regulation and completely focus on marketing and growing the funds.

He further explained: “For example, at the commencement of the programme in 2005, intermediate surgeries like caesarian section was denominated at ₦55,000.00 appendixentomy was ₦35,000.00, and others. The question is does this amount reflect today’s economic reality?

“In order to take care of the actuarial suggested upward review, five percent of the contributions was agreed to be kept in a separate account as “Reserved Fund’’.

“Again, the HMOs voluntary volunteered five percent of their administrative fee to be deducted from source by the NHIS for two years. This fund was meant to be utilised by the NHIS and the HMOs to set up robust Information Communication Technology (ICT) infrastructure that would interact and interface with the operations of the HMOs most importantly monitoring of capitation disbursement and settlement of fee-for-service bills.

“It is disheartening to know that the five percent deduction is still ongoing till date and the suggested ICT platform was never implemented. Instead, NHIS decided to hire hundreds or thousands of staff, created offices in the 36 states of the federation while by law, NHIS is only allowed to establish zonal offices in the six geopolitical zones.

“For all quarterly payment transmitted to the HMOs, the NHIS send staff to the HMO’s office for payment reconciliation that the HMO’s suggested should be done electronically. The NHIS can monitor payment through customized software like the Remita.”

What is the way forward? 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 utilise 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.