During the presentation of the National Health Insurance Scheme (NHIS) Digital Transformation Framework in Abuja, Chairman of the Economic and Financial Crimes Commission (EFCC), Abdulrasheed Bawa, raised the issue of health facilities that reject patients who have been paid for under the health insurance scheme. He urged the NHIS to sanction healthcare facilities that refuse to treat such patients.
Such rejection was not envisaged under the NHIS, established by the Federal Government, which became operational in 2005 based on a public-private arrangement involving the NHIS, Health Maintenance Organisations (HMOs) and healthcare providers. The NHIS accredits HMOs and healthcare facilities for the benefit of enrollees.
The NHIS is a social security programme driven by a pool of funds from contributions by stakeholders and guarantees the provision of healthcare to enrollees under a pre-payment system meant to reduce out-of-pocket payment. This is why refusal to treat patients under the scheme is a violation of its essence.
The HMOs have been accused of “operating with impunity” by defaulting on payment to healthcare facilities, which has created distrust in the system and encouraged the rejection of patients under the scheme.
The NHIS, which is supposed to be the regulator, has been accused of regulatory failure, which makes it possible for the HMOs to allegedly operate with impunity.
”Delayed payment especially from HMOs, denial of some payments under the fee-for-service arrangement, powers of the governing council, review of capitation, all need to be addressed,” the medical director of a NHIS-accredited hospital in Lagos, Jimmy Adeyeye, was reported saying.
Reflecting the need to rethink the scheme, the National Assembly passed the National Health Insurance Act (Repeal and Re-enactment) Bill, 2021, in April 2020, and the Senate amended the bill in December 2021. The new bill, which makes health insurance mandatory for all Nigerians towards achieving Universal Health Coverage (UHC) in the country, is expected to improve the implementation of health insurance.
The laudable goal of universal health coverage is to enable all people to have access to the health services they need, when and where they need them, without financial hardship.
Importantly, the Nigerian Medical Association (NMA) has urged President Muhammadu Buhari to sign the bill into law without further delay, saying it would facilitate universal health coverage in the country.
The scheme was supposed to achieve universal health coverage within 10 years of its operation, which it has evidently failed to achieve. According to the 2018 Health Maintenance Organisations (HMOs) Industry Report by Agusto & Company, only about five to six million federal civil servants and their families, and a few private-sector employees, were covered by the scheme. The country’s population was about 195 million at the time.
With Nigeria’s population in 2022 estimated to be about 214 million, it is doubtful if there has been significant increase in the percentage of those insured under the NHIS.
The introduction of the Digital Transformation Framework, also known as eNHIS, is a commendable move to improve the health insurance programme. NHIS Executive Secretary and Chief Executive Officer Prof. Mohammed Sambo stated that the health insurance regulator had hitherto depended on manual processes and rudimentary technology in the operation of health insurance, and critical data was hosted outside the country by a South African firm.
The eNHIS, which ensures automation of health insurance operations, is the fruit of collaboration between the NHIS and the Nigerian Communication Satellite (NIGCOMSAT). The benefits, according to Sambo, include connectivity among stakeholders, real-time service provision and resolution of complaints, data analytics and effective call management system.
Ultimately, however, the NHIS must firmly enforce compliance with the regulations, without which the scheme cannot succeed. The issue of healthcare facilities refusing to treat patients covered by health insurance must be addressed with a sense of urgency, and irregularities in the healthcare financing chain effectively tackled. Under the NHIS, the slogan, “the enrollee is king,” should be factual.