By Okechukwu Emeh
The lofty and innovative idea of Social Health Insurance Programmes (SHIPs) in Nigeria was informed by the overriding need by government to ensure that all citizens have access to good health care services through different segments of the programmes.
Namely, the programmes are: the one packaged for the formal sector (comprising federal, state and local governments, organised private sector, armed forces, police and other uniformed services and students of tertiary institutions) The second is the one packaged for the informal sector (community based and voluntary contributors), while the third is for the vulnerable groups (including physically challenged persons, prison inmates, pregnant women, children under five, refugees, victims of human trafficking, internally displaced persons and immigrants). At present, the enrolees (or subscribers) of SHIPs in the country are mainly Federal Government workers whose monthly contributions to the programmes are augmented by those of their employers.
As the institutional framework for coordinating, regulating and monitoring the implementation of SHIPs in Nigeria, the National Health Insurance Scheme (NHIS) was established in 1999. Among other roles and responsibilities, NHIS is charged with setting guidelines and standards for the programmes, accrediting Health Management Organisations (HMOs) and Health Care Facilities (HCFs) or Health Care Providers (HCPs), carrying out continuous quality assessment to ensure effective and efficient health care services and programme management.
Considering the centrality of excellent health in the actualisation of one’s full potentials in life, it is worrisome that the noble vision of the social health insurance scheme has somewhat been blighted in Nigeria. Several irrepressible factors are blameworthy for this lamentable situation. As concerning NHIS, the factors include inadequate funding, failure to reposition the agency for untrammelled discharge of its regulatory, monitoring and enforcement functions and obligations, dwindling trust of many enrolees in SHIPs due to corruption, inefficiency and political patronage that bedevilled the programmes over the years, poor data formulation on all subscribers that has made the health insurance scheme to be prone to fraud and wastage and non-extension of universal health care coverage to all Nigerians.
For HMOs, the unenviable role they have played in dwarfing the development of SHIPs is egregious in their late payments to health care facilities, irregular and unsatisfactory quality assurance of accredited hospitals, late approval of referrals and the associated follow-up to complete the process, delay in making requisite payments to the appropriate pools in a timely manner and not effecting necessary returns to NHIS in conformity with its Operational Guidelines. On the part of HCFs, they have become a stumbling block to the implementation of the health insurance scheme by not ensuring enrolees’ satisfaction through better Medicare, disregarding provision of services as agreed with HMOs in the benefit package, non-compliance with NHIS Operational Guidelines and not providing returns on utilisation of services and other data to the regulatory body through HMOs.
Arguably, the aforementioned factors and others have threatened to jeopardise the full development of SHIPs in Nigeria. The factors have also buoyed the jeremiad tales of many enrolees in the programmes owing to their inability to access medical services from some of the HCPs with ease. For such soulless health care providers, they have been accused of treating their patients with sheer apathy, disrespect and exploitation despite being financially dependent on the contributions of NHIS subscribers for their operation. Besides, HCPs enjoy the monthly capacitation of N750 per enrolee from the regulatory agency, whether medical service is offered or not and yet some of them fail to render efficient service. On the other hand, HMOs, as the custodians of health insurance funds, have fed fat on the contributions by not releasing them to HCPs as and when due, alas affecting health care delivery service to NHIS patients. This is not to mention the vexed issue of some of the health insurance managers not effecting necessary returns to the regulatory body in line with its Operational Guidelines.
Such sickening spectacles in the implementation of SHIPs in Nigeria are small wonder there is underlying assumption in some quarters that the programmes are a huge fraud worse than the controversial fuel subsidy regime on account of human suffering and deaths stemming from their abuse by some of the errant HMOs and HCFs. The social health insurance scheme is also viewed as being grossly skewed towards these bodies rather than the enrolees that are supposed to be in the driving seat of the scheme. This is what was formerly found in the flawed health care systems of advanced countries that Nigeria copied from like the United Kingdom (UK) and the United States (US), which their governments have taken far-reaching reforms to improve.
For example, under the outgoing President Barack Obama in the US, the revised health care scheme there is tagged “Obama Care”, which provides for millions of Americans that were left out of the old system that was adjudged in certain quarters as not only dysfunctional but also inequitable and wasteful.
Not helping matters in the sad fate of SHIPs in Nigeria is the inability or refusal of NHIS to stamp its regulatory and enforcement authority on HMOs and HCPs. Of course, this has given carte blanche for some HMOs to abdicate their roles and responsibilities or gravitate towards dictating to the regulatory agency on how to implement the health insurance scheme. And for some HCPs, to show blithe disregard for the enrolees and patients of the scheme.
It is germane to note, however, that the contradictions that have thrown a spanner in the works of social health insurance programmes in Nigeria were mostly observable before the appointment of Prof. Usman Yusuf as Executive Secretary/Chief Executive Officer of NHIS by President Muhammadu Buhari last July. Prior to his present position, Yusuf was a topflight medical scholar and expert in bone marrow transplantation for children with terminal diseases like cancer of the blood, practising first in Nigeria, followed by the UK and later the US. From all accounts, many watchers of the health care industry in Nigeria are optimistic that he would be instrumental in repositioning NHIS to be a world-class social health insurance regulator.
This is considering his reputable track records as a professor of paediatric haematology and oncology, coupled with his transparent honesty and dedication to duty, which would mark the beginning of a new era in the agency.
Emeh writes from Abuja via [email protected]