NHIS crisis deepens as Minister faces arrest

EMEKA EJERE|

There appears to be no end in sight to the crisis rocking the National Health Insurance Scheme (NHIS). The House of Representatives’ Committee on Health Services on Wednesday threatened to issue warrant of arrest against the Minister of Health, Prof Isaac Adewole, if he fails to clarify issues on the suspension of the scheme’s Executive Secretary, Prof Usman Yusuf.
The House had on Wednesday, 12th June, 2017 resolved to invite the Health Minister “to show cause why he should not be cited for contempt of the House as the suspension of the Executive Secretary of NHIS, appears to be intended to intimidate and punish him for testifying before the House and silence him for further testifying before the House of Representatives in its constitutional duties of investigation of issues of corruption, inefficiency and waste in governance.”
The battle line was drawn by the chairman of the committee, Chike Okafor, after deliberating on the letter written by the Minister where he (the Minister) specifically stated that he would not appear before the Committee on Thursday, 27th July, 2017.
Okafor while stating the unanimous decision of the Committee members discharged the Acting Executive Secretary, Ibrahim Attahiru with the proviso that the lawmakers would treat the NHIS budget as soon as the Minister appears before the committee to resolve the NHIS issue.
“The House resolution was communicated to the Health Minister and if you look through our proceedings, you will see that we were expecting the Minister to come tomorrow (today) to give us an update on the crisis rocking the NHIS.
“But incidentally, I got a letter from him about an hour ago, saying he will not be available to appear before this committee.
The House Committee recently held a 2-day investigative public hearing aimed at achieving three key objectives – to investigate the compliance rate of Health Maintenance Organizations (HMOs) to the NHIS contributions; to investigate the utilization of funds by the Healthcare Providers; and to investigate the claims of inhumane treatment of enrollees.
Stakeholders at the hearing were an interesting mix of House Committee members, the Federal Ministry of Health (FMOH), NHIS employees, HMOs, Healthcare Providers, those that came to represent the enrollees, the Nigerian Labour Congress (NLC), the Trade Union Congress (TUC), and various Civil Society Organisations (CSOs).
Weeks after the Senate launched investigations into his activities as the NHIS chief, Prof Yusuf was suspended for three months by the Health Minister with immediate effect in the interest of his investigation by the Senate, according to the Health Ministry.
Mr. Yusuf, 54, took over the state-run health insurance provider on July 29, 2016, but his reign has been fraught with allegations of fraud.
The senators accused Mr. Yusuf of “corrupt expenditure of N292 million” which he allegedly spent on health care training “without recourse to any appropriate approving authority.”
Shocking revelations
Represented by the Director of Hospital Services, FMOH, Mr. L H Balami, Prof Adewale opined that, “It is not mandatory for HMOs to exist as there are many countries that operate without HMOs, so the committee should investigate the merits and demerits of HMOs.” Countries such as Kenya and Zimbabwe have been able to achieve better health care delivery without HMOs.
Balami revealed that the Federal Government has paid about N351 billion to HMOs in the last five years without seeing appreciable results in health care delivery and insurance coverage.
“The Federal Government pays 5% of consolidated salary as a premium to NHIS who pays HMOs. 70% of the funds are required to be paid immediately to health care services providers to provide care for those paid for. Failure of immediate transfer is a punishable offence by law,” he said.
“The role of expanding coverage is the role of NHIS and not that of HMOs, and thus the House Committee has the right to review the allegations of the diversion of funds,” he said.
He noted that Universal Health Coverage (UHC) was dependent on a system which allowed for access to health services for everyone. “The House Committee looks forward to a more efficient system which emphasizes patient-centered care since access to affordable and key health services is a key element in UHC,” he said.
Presenting his case at the public hearing, Prof. Yusuf who hailed the 8th Assembly as “The only Assembly that has brought HMOs to book for their misdeeds,” hammered on the impact the lack of health coverage has on Nigeria’s national health statistics.
“Over hundred women die daily from child bearing. The statistics are so bad that we do not have the luxury of time to be fighting”, he said.
He again pointed out that “The real number of Nigerians covered by NHIS is 1.5% after 12 years,” and insisted that, “NHIS should help vulnerable people access healthcare and UHC means we should cover 180million Nigerians.”
For him scraping the HMOs will make the scheme more fruitful. “The one thing countries doing better at achieving UHC have done is to do without HMOs. I see a potential of NHIS to directly fund healthcare in Nigeria,” he said, adding that “NHIS handed over enrollment, money and regulation to HMOs.”
At least N351 billion in health insurance funding has gone with the wind in the last five years through 57 HMOs, without paying for service.
“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,” said Yusuf.
He claimed that many HMOs owed hospitals the NHIS funds and that his goal was to ensure they paid back all they owed, adding that there was an HMO that owed NHIS N400 million.
He alleged that some of the HMOs had formed a “cabal” and said, “I was told not to rock the HMOs boat but what I will do is sink this boat of corruption.” He positioned himself as on the side of the people.
“I am here to fight for the enrollee, which includes all of us. We all live one major illness away from poverty. NHIS will help cushion that effect. I will put the enrollee in the driver’s seat; he will choose to fire his HMO.”
He reaffirmed his plan to reaccredit all 57 HMOs in Nigeria in July, and said that none of the HMOs were currently licensed. He then concluded with five recommendations for the house committee which he implored the lawmakers to adopt:
“NHIS should hand the money for services directly to the hospital; a full investigation should be instituted on the HMOs; lawmakers should institute mechanisms that would “help NHIS increase coverage,” expel HMOs from the NHIS board, hold NHIS and the Executive Secretary accountable.”
However, in his defence, President of the Health & Managed Care Association of Nigeria (HMCAN), the umbrella body of HMOs licensed operators of NHIS, Dr. Leke Ewenla, claimed that the public hearing was the first time that the Executive Secretary had sat down with the HMOs to have a conversation, and that his attitude towards HMOs was aggressive and made them look like culprits.
He said that most people do not understand the concept of health insurance.
“The current NHIS fund is 10% of annual basic salary of civil servants paid by the Federal Government to healthcare providers through HMOs to provide customized services,” he said, adding that the scheme in question at the hearing was not meant to cover all Nigerians as the Executive Secretary was insisting.
He raised issues with the NHIS’s recent decision to pay capitation monthly rather than quarterly, pointing out that insurance is meant to be paid annually but the quarterly payment was a system agreed upon between NHIS and the HMOs, noting that the issues with the system arose from lack of regulation on the part of the NHIS.
Speaking on behalf of the enrollees, President of the Nigeria Labour Congress (NLC) Comrade Ayuba Waba, noted:
“The enrollees are the major stakeholders; every other person is a parasite, feeding off the enrollee. The enrollees are not getting better services and have not gotten the desired result”.
He then stated explicitly, “We don’t think the HMOs have a role in building and strengthening the NHIS, we can do without them.”
Comrade Boboye Balakaigama of the Trade Union Congress, called on the House to “conduct a very strong forensic audit of the entire system” advising the Executive Secretary of NHIS to “prioritize your battles” and asked that after the audit, “a law should be put in place to address the lacuna we’ve discovered.”
Dr. Kingsley Ekweremadu of the Nigerian Medical Association (NMA) raised issues that he felt affected health care coverage in Nigeria. He said that the “majority of Nigerians are excluded because enrolment is voluntary,” adding that there is a “low level of awareness by people due to poor sensitization of enrollees.”
Whose fault?
A senior lecturer at the Adeyemi Federal College of Education, who pleaded anonymity, observed that the NHIS has been politicized and hijacked by dubious people who want to enrich themselves at the expense of the Nigerian masses.
“Some HMOs collect money and they don’t pay the healthcare providers, while some only pay insignificant amount to the hospitals, who in turn give low quality treatment to the enrollees.
“In fact the scheme is only enriching politicians and there cronies. I once used the NHIS but opted out when I discovered that it had nothing to offer.
“I then enrolled in the healthcare scheme run by my institution, and I can tell you I’m satisfied with what I’m getting. This scheme also covers your spouse and four of your children.”
On her part, a nurse/midwife with Unilever Nigeria, Miss Lois Ndulaka, once worked with Eko Hospital, Lagos. She shares her experience with the NHIS while at Eko Hospital.
“The NHIS is the worst scheme anybody can be part of. Government should take a second look at that scheme,” she said.
“At Eko Hospital, NHIS patients receive the least attention because the HMOs pay peanut on their behalf.
“For instance, if private sector firms pay N10,000 for a patient, NHIS pays N1 for an enrollee. It’s as bad as that.”
However, a deputy manager at the Nigeria Social Insurance Trust Fund (NSITF), Mr. Cyprian Irom, said his own HMO, Pro-Health is not doing badly.
He, however, noted that the hospitals do not give one attention beyond the strength of subscription category.
The NHIS delisted HMOs in an attempt to recoup some money. They are up for re-accreditation this July and must provide a letter from hospital directors indicating the HMOs do not owe any debts before they can apply to manage any hospital. It is alleged that HMOs owe hospitals N3.5 billion.