‘NHIS can only regulate not implement health insurance in Nigeria’

In recent times, the National Health Insurance Scheme (NHIS) and the parent body of Health Maintenance Organisations (HMOs) in Nigeria, Health and Managed Care Association of Nigeria (HMCAN), have been having conflicts of interests.

While the NHIS is accusing the HMOs of corruption and complicity with health care providers that is retainer hospitals to defraud the scheme and unsuspecting patients, HMCAN is saying that the government agency is playing a dual role of on the regulator and the regulated or implementer.

The Executive Secretary of NHIS, Prof. Usman Yusuf, even threatened to drop the HMOs for alleged corrupt practices if they did not put their houses in order.

What is the way forward?
A consultant physician/neurologist at the College of Medicine University of Lagos (CMUL)/Lagos University Teaching Hospital (LUTH), Prof. Mustapha A. Danesi, in an exclusive interview with The Guardian said in order to make it for smooth running of health insurance in the country, the NHIS should come in as regulator where as the implementer will be the HMOs.

Danesi warned that when the government tries to implement as well as regulate there will conflict of interest and by the end of the day the scheme will just suffer and will not succeed.

He explained: “There is a lot of misunderstanding on the part of government officials. We have to decide if we want to have health insurance, then government comes in as a regulator. The law is there and everything is stated clearly in the law. If there is anything wrong with the law they will amend it. In order to make it for smooth running, they come in as regulator where as the implementer will be the HMOs. They should be the ones to implement it while government regulates the implementations. Once government tries to implement as well as regulate there will conflict of interest and by the end of the day the scheme will just suffer and then it will not succeed.

“So at present the government seems to dabble into implementations rather than keep strictly to regulation and I believe it is in the interest of everyone to make sure that government keeps to its role as regulators and facilitator. Regulation means make sure that the laws are implemented and make sure every accredited HMOs are quality HMOs, and make sure that accredited health care providers are quality providers. Those are regulatory issues and make sure that the money that is paid is properly kept and disbursed to the HMOs in other to pay the providers and so on, and that is facilitation. If we are housing the money that is paid, disburse it as fast as possible so that there will be no hitch in the implementation.”

On whether the NHIS can drop the HMOs for alleged corrupt practice, Danesi said: “I am worried if you have the executive secretary that thinks he can do without HMCAN. It means he does not understand how health insurance works. So who is going to implement it? Does he want to implement it? It will crash.”

What is your advise to the NHIS boss?
He said: “I am not familiar with the current executive secretary. I heard he came from America. I do not think he understands what is going on now in the country because an executive secretary should be able to have a deep understanding on how health insurance works and by the time you said you can do without the HMO it is a serious issue. When you do away with the HMO, who is going to run the scheme? It will collapse. Government is supposed to be a regulator will the private sector, the HMO, are to be the implementers. There is a definite criterion on how the HMOs relate to the providers and there is what is called documentation. Everything is documented so by the end of the day the providers are given capitations and then there is difference between premium and capitation.

“The premium is given to HMO; the HMO gives capitations to health providers, primary providers who use this to do primary health care and then they can retain part of the premium for tertiary healthcare, for specialists. This money is spent as it is contributed. Insurance means you are having a pool of fund that is ready for those in need to use it. If you understand insurance it does not mean that if I contribute N1,000 that I must get that N1,000 service. Then it is no longer insurance. The reason why I can contribute N1000 is that when am broke, I need to spend N50,0000, spreading the risk.

“You find out that if 2,000 people pay N1,000 that will be N2 million and out of the 2,000 people may be about 100 maybe ill that month and those are the ones to be taken care of. Meanwhile the manager collects the money and keep it, any of those who are ill he will take out of the money, those who take capitations for 2,000 takes that and anybody who is ill it takes care of him or her no matter the cost since he or she has been paid for as in capitations. It is insurance, one needs to have a deep understanding of the working of insurance before bringing issues of corruption.”

What is the solution?
The neurologist said: “The executive secretary, his role should be to enhance the health insurance and at present we have very low enrollment. He should work in harmony with the HMOs and the providers as stakeholders. They should sit down and work out how best to have a good insurance system for the country instead of fighting each other. The bane of the healthcare is that the government is in competition with the private sector rather than corporation. They start having their own health system where the private sector has theirs and each is competing with the other. The best approach is not to have government having health care system into competition but in corporation.

“Everybody should sit down as stakeholders and make arrangement whereby everybody is involved in providing healthcare and healthcare finances arrangements with the such that it doesn’t matter whether you are going to government or private hospital. The payment system has been taken care of by an adequate insurance system.”