Many lapses in NHIS implementation
Bola Adeniran is the Chairman of Pharmaceutical Society of Nigeria (PSN) Lagos State Branch; a Fellow of the Society and a former member of the Pharmacists Council of Nigeria (PCN) Governing Council. She has been a member of the PSN (Lagos State Branch) executive for over 13 years in various capacities. Adeniran, in a chat with journalists, identified the many lapses in the current implementation of the National Health Insurance Scheme (NHIS), leading to the near exclusion of all other care providers except medical doctors in the evolving scheme. The pharmacist advised the Lagos State Government against towing the path of the NHIS as she plans to roll out her own scheme later this year. She also spoke on the expectations of the Annual Pharmacy Week of the PSN, which comes up in August among other things. CHUKWUMA MUANYA (Assistant Editor) was there. Excerpts:
There was a lot of uproar at the House of Representatives this week following an investigative hearing into the disbursement of N350 billion to some Health Maintenance Organisation (HMOs) by previous leaderships of the NHIS. What are the challenges of Social Health Insurance in Nigeria?
The National Health Insurance Scheme (NHIS) was established by Act 35 of 1999 to promote easy access to health care delivery for all Nigerians through the instrument of Social Health Insurance. It is also to promote qualitative health care delivery, public/private partnership and equitable distribution of health facilities across the nation. It was indeed meant to promote professionalism and streamline roles of Healthcare Professionals.
In developing and industrialized countries, alike, efforts to provide healthcare, including pharmaceutical care are facing new challenges. These include the rising cost of health care, limited financial resources, a shortage of human resources in the health care sector, inefficient health systems, the huge burden of diseases and the changing social, technological, economic and political environment which most countries face. While globalization has brought countries closer together in trade of, products and services and in recognition of academic degrees and diplomas, for example, it has led to rapid changes in the health care environment and to new complexities due to increased travel and migration.
Access to medicines of assured quality remains a major concern worldwide. One third of the world’s population, do not yet have regular access to essential medicines. For many people the affordability of medicines is .a major constraint. Those hardest hit are patients in developing and transitional economies, where 50 per cent to 90 per cent of medicines purchased are paid for out-of-pocket. The burden falls most heavily on the poor, who are not adequately protected either by current policies or by health insurance.
The PSN conscious of the expanding role of its members in healthcare delivery and the value added impact on patients where pharmacists interventions are guaranteed, continues to put on record the many lapses in the current implementation of the NHIS, which has led to the near exclusion of all other care providers except medical doctors in the evolving scheme.
In one of the most embarrassing reflections in contemporary times, the United Nations rated our health system a wretched 187 out of 191 nations of the world. Even war-ravaged countries were far ahead of us. The only reason remains our inclination to a Nigerian style of healthcare practice. One would have expected the NHIS to help correct some of the aberrations, which have prevented proper stratification of services along well-defined health tiers via primary, secondary and tertiary.
Today, under the deceit of; “easy access to care facilities” which negate valid Acts of Parliament, NHIS capitates secondary and tertiary healthcare facilities, Hospitals and Clinics are also encouraged to run in-house pharmacies with quacks or auxiliary nurses thus compromising the quality of healthcare dispensed in these facilities. This encourages such facilities to take over core primary care function from the ideal primary care centres. In a country where 60 per cent of clinical visitations are malaria based, patients will continue to visit teaching hospitals for malaria while distracting these centres from handling the specialist cases and research they were conceived for. A care centre that inculcates specialist services, diagnostic facilities and so on is certainly no longer a primary care centre. This is why in tune with global practices only Primary Healthcare Centres (PHCs), nursing care homes, comprehensive health centres, clinics and Out Patient Departments (OPDs) of non-specialist hospitals should be capitated as gatekeepers or primary providers in managed care.
Today the experience in Nigeria is that enrollees in Nigeria’s version of Social Health Insurance that is unprecedented anywhere in the world as most renowned teaching hospitals (tertiary) and other secondary facilities at state government level especially are capitated.
What this has done is a drift of the enrollee pool to established public health facilities. The reality in Nigeria is that the NHIS has become a public Sector driven concept rather than the norm of private sector led initiative.
The various fundamental distortions in managed care are responsible for the refusal of State Governments, private sector and professional associations to key into the vision of Social Health Insurance. Prior to the incumbent management team of the NHIS, coverage was less than two per cent of the estimated population of 170 million. Even the Executive Secretary, NHIS now puts enrollee base at 7.2 million after his first year.
If Rwanda has an enrollee base of 92 per cent, Ghana 60 per cent and Nigeria has about 1.75 per cent after 12 years of implementation of the NHIS, then it is obvious that the Frankenstein monster called the Nigerian factor is at work yet again in an endeavor which optimists had imagined would bring far reaching reforms to the totality of the healthcare industry in our country.
How about the issue of capitation?
Perhaps, the biggest of the fraud on the NHIS remains the implementation of the unlawful concept of global capitation. For the records, the only lawful payment mechanisms in the statutes (Act 35 of 1999) manuals and guideline of the NHIS are: capitation, fee for service, case payment, and per diem.
The global capitation concept was a shortcut devised by HMOs for administrative convenience to suit them but which short changes other key stakeholders. Global capitation involves payment of capitation and all elements of other payment modes meant for other providers (secondary and tertiary) to the primary provider.
This system compromises service delivery to the enrollee because he is not guaranteed the best drugs or diagnostic services since the primary provider who has been paid upfront for these services tries to maximize his profit from the advanced payment. Similarly, the Nigerian factor is such that the primary provider can hold the secondary and tertiary providers to ransom when he diverts monies collected for their services to other use. In such situations, how is the pharmacist, who dispenses upfront and waits for four week to be paid or other care-providers, protected adequately.
This is why the HMOs must be made to pay secondary and tertiary providers after signing contract agreements in line with provisions of the law. A need also arises to tackle the excesses of HMOs .who have interests in same provider network or facilities and therefore take advantage of their privileged position to divert a huge chunk of enrollees to these facilities. Nigerians would also continue to pay a high cost for healthcare for as long as Government continues to encourage health providers to render services not within their immediate areas of due competence For instance WHO studies revealed that private health clinics were shown to charge up to 184 per cent more than the public health facilities and 193 per cent more than private retail pharmacies in Nigeria for drugs. Yet, Government continues to overtly and covertly supports these private clinics to dispense drugs thereby increasing overall cost of healthcare to Nigerians.
Despite our misgivings arising from the poor implementation of the scheme, we believe that NHIS is one of the most credible alternatives for funding healthcare in Nigeria. It is assumed that this scheme will offer equitable and physical accessibility to the enrollee but in our assessment, the scheme is yet to ensure delivery of efficient, quality assurance, effectiveness, sustainability and harmony amongst providers. We are at a loss as to why the prescribed working guidelines that were extensively reviewed and rehearsed by stakeholders were never tried.
In the light of what looked like a failed scheme at the National level, what advice do you have for the Lagos State Government, which plans to roll out its own scheme later this year?
I must thank you for this very appropriate question. Sometimes between 2008 and 2009, one of our past Presidents, Olumide Akintayo, had pointedly told a stunned audience at a NHIS retreat in Bauchi that all that was going on in the guise of Social Health Insurance in Nigeria was thievery because privileged persons at the NHIS Secretariat and some of the chieftains of leading HMOs were just sharing money. This scam which is now established as per events at the investigative public hearing is probably worse that the fuels subsidy scandal of some years ago because the system under the guise of eliminating out of pocket expenditure in the health system was actually milking enrollees who were shortchanged with extremely poor services. In undocumented instances you know that the direct fallout of this unfortunate agenda remains morbidity. As the Lagos State Government plans its roll out, I find it necessary to make passionate appeals that we learn from the experiences at national level.
The PSN warned as early as August 16, 2006 at a review meeting held at Reiz Continental Hotel, Abuja that the NHIS would fail as long as fundamental issues with regards to unlawful payment mechanism, indiscriminate capitation, need to embrace a public sector driven concept and getting drug manufacturers and importers to design affordable drugs for the scheme were not redressed. Why will anybody want to pay another service provider (primary provider) and add bills of secondary providers (fees for service) to it when the various professions are autonomous. Healthcare we continue to say is a global practice, which favoured people cannot continue to mutilate to get a Nigeria style of practice.
The defective NHIS model is the roadmap the Lagos State Ministry of Health has set for the Lagos State managed care programmes. At federal level, disbursement of N351 billion employing this mode gave coverage of 1.75 per cent in 12 years. You see that it was a lot of retrogression. We do not want this for our dear Lagos State presumably because it is perceived as a centre of excellence. The mega city vision is on course with massive consolidation of infrastructures everywhere in the landscape; Governor Ambode has a unique chance to amplify these gains with quality healthcare by going back to the drawing board to immediately deal with the defect and loophole laden managed care scheme the experts at Lagos State Ministry of Health intend to bequeath to the citizenry. If urgent steps are not taken to rectify things now, the scheme I dare say is dead on arrival.
The Annual Pharmacy Week of the PSN comes up in August. What are the expectations?
The usual thrills and frills. We will showcase a new and unprecedented dimension in scientific exposition. We shall design templates for our young folks to meet mentors in the profession because they are the future of the profession who will be primed to raise the bar.It is our expectation that the over one thousand pharmacists, health workers, care givers and consumers of health that will be in attendance will enjoy the benefit of insight into recent advances in the pharmaceutical sciences.