Last week, the House of Representatives Committee on Healthcare Services 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
- To investigate the claims of inhumane treatment of enrollees
With the new and vocal Executive Secretary of the National Health Insurance Scheme (NHIS), Dr. Usman Yusuf attending the public hearing, it was bound to be an engaging mix of hard hitting facts, accusations and counter-accusations and yes, even humour. The Nigeria Health Watch team attended the first of this kind of hearing and put together a synopsis of the main arguments from the stakeholders’ present.
The stakeholders were an interesting mix of House Committee Members, the Federal Ministry of Health (FMOH), NHIS employees, Health Maintenance Organisations (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).
Hon. John Okafor, Chairman, House Committee on Health Care Services, in his emphatic opening remarks noted that the “National Assembly has a crucial role to play in catalyzing the transformation of the health sector.” He set the tone for the public hearing with three crucial questions to key stakeholders:
- “Must we have third party payers (HMOs)?”
- “Is there any problem with paying hospitals directly?”
- “How do you feel about the tears and cries of the enrollees?”
Prince Chukwuka Wilfred Onyeama, Minority Leader of the House of Representatives had specific statements to the general public and stakeholders at the hearing. Speaking on the challenges which the committee was set up to address, he said, “There is no mechanism to protect families from catastrophic emergency health expenses. Today’s public hearing presents an opportunity and I urge all involved to bare all issues so they can be thrashed out. The time for theatrics is over and the National Assembly will partner with all stakeholders to ensure the needs of the enrollees are met.” He urged members of the public to develop a habit of opening up at public hearings such as this to help lawmakers effectively do their work.
The Ministry of Health
Minister of Health Professor Isaac Adewole was represented by the Director of Hospital Services, FMOH, Mr. L H Balami. His address to the committee included key statements regarding the NHIS and the existence of HMOs. He 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 noted that the Federal Government has paid about N351 billion to HMOs, 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.
He applauded the investigative public hearing and lauded the Committee for its efforts. “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.
The Executive Secretary, NHIS
NHIS Executive Secretary Prof. Usman Yusuf was at the public hearing to present his case against HMOs. Not one to mince his words or hesitate, he got right to it by hailing the 8th Assembly as “The only Assembly that has brought HMOs to book for their misdeeds.”
He hammered on the impact the lack of health coverage has on Nigeria’s national health statistics. “Over a 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 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.”
The Executive Secretary had no qualms about his desire to end any system that included using HMOs for service delivery. “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.” The Executive Secretary claimed that many HMOs owed hospitals and 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.
In his closing remarks, the Executive Secretary had five recommendations for the house committee which he implored the lawmakers to adopt:
1) NHIS should hand the money for services directly to the hospital
2) A full investigation should be instituted on the HMOs
3) Lawmakers should institute mechanisms that would “help NHIS increase coverage”
4) Expel HMOs from the NHIS board
5) Hold NHIS and the Executive Secretary accountable.
The Health Maintenance Organizations (HMOs)
Dr. Leke Ewenla, president of the Health & Managed Care Association of Nigeria (HMCAN), the umbrella body of HMOs licensed operators of the National Health Insurance Scheme, gave an impassioned speech in defense of HMOs after the blistering accusations leveled at them by the Executive Secretary NHIS. He 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.
He noted that the issues with the system arose from lack of regulation on the part of the NHIS.
According to the African proverb “When two elephants fight, it is the grass that suffers”. This time the ‘grass’ refused to be quiet as the enrollees, represented by the Nigerian Labour Congress (NLC) and the Trade Union Congress (TUC) took a cue from the words of Prince Wilfred Onyeama, and laid bare their concerns.
Comrade Ayuba of the NLC gave many in the audience something to applaud to, with his opening remarks that: “The enrollees are the major stakeholders, every other person is a parasite, feeding off the enrollee.” He expressed the concerns of many when he said that, “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 employed a more eagle-eyed approach and called on the House to “conduct a very strong forensic audit of the entire system”. He also advised the Executive Secretary 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.” He also pointed out that “We need to establish a formal complaint system that addresses the issues of poor healthcare delivery.”
Committee’s next steps
In an interview with Nigeria Health Watch, Hon. Chief Chukwukere Austin Ikechukwu (JP) of the House Committee on Health Care Services gave an overview of the conclusions arrived at from the hearing.
“What we did was to hear from the stakeholders,” he said, adding, “We will work with the information we have been given to investigate the issue. A subcommittee has been set up to look into the books of the HMOs, following the accusations of the NHIS to see where the leakages are. We will investigate HMOs depending on the information we have from NHIS, of which HMOs are owing and which ones are compliant.”
The Chairman of the House Committee on Healthcare Services, Hon. John Okafor, during the public hearing implored with the Executive Secretary to hold off on his plans to reaccredit all HMOs in July. Hon. Ikechukwu pointed out that this was to allow the committee finalize their investigations and make their recommendations to the House.
He noted that there was no specific time frame for the investigation. “One thing may lead to another, so I do not want to put a time frame on the investigation,” he said, adding, “We are going to be as quick and as smooth as possible and the House will take decisions based on what we find out.”