‘Weak law, poor implementation responsible for low health insurance coverage’
LEKAN EWENLA is the national publicity secretary of Health and Managed Care Association of Nigeria. In this interview with ANTHONIA OBOKOH, he explains why health insurance coverage in the country has remained abysmally low more than 12 years after it was introduced. He also suggests ways to get the scheme working efficiently.
Enlighten us on the different types of health insurance presently running in the country?
There are two or three types of health insurance running in this country as we speak today; we have the private health insurance scheme that is running for the Organised Private Sector. That one is called Managed Care, in the sense that individual organizations pay their premium to the health maintenance organizations (HMOs), the HMOs now request the hospital or facility to send or give their own treatment tariff. Now, we use the tariff and the volume of enrollees in that particular facility to negotiate the tariff, especially those that are found to be on the high side. So the facility will send the bills to the HMOs, they look at the bills, vet the bills and settle the payments. The premium is paid to the HMOs.
There is another one called Public Sector Social Health Insurance Programme, which is mandatory for all federal civil servants and also covers their spouses and children under the age of eighteen. On that public sector scheme, there are two risks bearers: the primary healthcare provider bears the risk at the primary level and that is why we all hear about capitation. So, about 70 percent of the premium is paid up-front to the primary healthcare provider to bear the risk. The HMOs bear the risk at the secondary and tertiary levels. So a certain amount is equally paid to the HMOs to bear that risk at that level. Now what that means is that for all services that are provided at secondary and tertiary levels, the primary facility will need to call the HMOs for pre-authorisation code and once the HMO gives approval for that service to be provided, that means that facility will send the bills to the HMO for settlement. But the good news about that concept is that actually, services at that secondary and tertiary level were equally denominated such that it does not lead to conflict and confusion.
Long and short for the settlement of bills, I want to say there have been little challenges from most of our colleagues because they give approval and they do not pay. That is one of the issues that the ethics committee that has been set up will address.
The NHIS has only covered less than 10 percent of the Nigerian population within 12 years of its establishment, what can be done to deepen penetration?
It is simple and straightforward and we are already on that path now. Everywhere in the world where you see health insurance being embraced by everybody, it is made mandatory. Do not forget the fact that wherever the law is not strong, people do not comply, that is the issue here. So if the law is reviewed as we speak today and the health insurance scheme is made mandatory for all Nigerians, everyone will comply. I am very sorry to say this, but Nigerians do not comply with laws unless it is made compulsory, unless someone is there to enforce it. In other countries where you see things working, it is because they have put in place the implementation and enforcement structure for people to comply.
As we speak today, the National Assembly has set in motion the process of reviewing the scheme and before the end of this year, there is likelihood that the law may be reviewed and the scheme made compulsory. In the last seven to eight years we have created customised products, healthcare packages for some sub-sectors of the industry, and the coverage level as we speak today is still far less than 20-30 percent. We created a product for the tertiary institutions in this country; called TSHIP; the 59 or 60 private universities in the country are not on the scheme as we speak today. Why? Because the law is weak, therefore compliance becomes an issue. So, that is why the coverage volume is still low.
But while we are working on the law, moving forward, we are equally trying to work closely with the NHIS because the NHIS as the regulator can enforce the compliance on any employer of labour with minimum of 10 employees because the law has taken care of the organized private health sector which falls under formal sector. The law says precisely every employer of labour with minimum of 10 employees must or should or may provide health insurance coverage for their staff.
Since health is a basic human right, what is the role of the association in actualizing it?
With the challenges we have faced in the last one year, let’s say in the last 12 years that this scheme started in 2005, we have realized that it is important for someone to take ownership of the industry and that is what we have decided. We are ready to now engage with the critical stakeholders in this country so that everyone will begin to understand the fact that health is wealth.
How can HMOs help to achieve universal health coverage in Nigeria?
We are like the banks and pension fund administrators (PFA); we have developed innovations to take over the industry. What we are going to do now is to work closely with NHIS to begin systematic expansion and embracement of the customized product in any targeted industry. In the next couple of months or a year, If all the tertiary institutions can key into the health insurance scheme, the percentage of coverage will be over 15 to 20 percent because the number of youth that are between the age of 18 to 25 are above 20 million. That is what we are driving at right now, coupled with the committee of ethics recently introduced so that all stakeholders comply with standards. With the full support of the regulatory body which is NHIS, we are really working on achieving all these to expand the coverage. We will soon present our customized products to the NHIS and also design the implementation model to drive the expansion of the scheme while the national assembly is on the review of the law to make health insurance mandatory.
Kindly update us on the latest concerning the imbroglio between the NHIS and the HMOs?
A lot of challenges were witnessed in the last few years due to deliberate attempt to blackmail some critical stakeholders in the industry, but now that we have somebody that is ready to look at issues holistically, a committee was set up in the last 2 months which I think will be rounding off by now. All issues must be investigated because what was wrong has been identified and we cannot grow this sector when we have a whole lot of hostilities with the critical stakeholders. What we expected was a situation of mutual respect and understanding from each critical stakeholder of the scheme and everybody is guided by standards and rules.
What do you think needs to be done to improve the scheme in Nigeria?
Firstly, government needs to separate the grain from the chaff by identifying those agencies that require specialists to drive them so that appointments into such agencies like NHIS are not done politically but through a standard recruitment process. Whosoever is appointed to head such agencies should know what the scheme is all about because it is technical and scientific-based and not political, that’s the major reason health insurance has not grown in this country. Since inception till date, government has made those appointments based on politics but what we need is a standard level of recruitment to get a competent and knowledgeable individual to lead the scheme.
In addition, what the law says is that a governing council needs to be inaugurated for the agency because by law, the council will be the one to formulate laws for the scheme while the executive secretary runs the scheme based on those laws. So if there is no council, that leaves a whole lot of room for the executive secretary or the director general to run the agency like his or her personal empire.
The HMO suggest the implementation of a very robust software and information and communications technology (ICT) platform by the NHIS, also want to put it on record that we the HMOs voluntarily volunteer the deduction of 5% of our administrative fee for this purpose because we are aware the scheme can only run efficiently with information technology.
The ICT platform will help the NHIS to generate data’s. The software will also help to monitor HMOs solely on private sector scheme. Until that ICT platform is established we are going nowhere.