Are HMOs needed in Nigeria? Public hearing scrutinizes their existence

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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
A full house on the first day of the investigative public hearing on HMOs contributions to the NHIS by the House Committee on Healthcare Services. Photo Credit: Nigeria Health Watch

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).

The House Committee on Healthcare Services listened to different stakeholders argue on the contributions of HMOs to NHIS and to the whole concept of Universal Health Coverage in Nigeria. Photo Credit: Nigeria Health Watch

The Committee

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.

Several groups came out to support different stakeholders at the hearing, most visibly the NHIS team. Photo credit: Nigeria Health Watch

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.

Prof. Usman Yusuf, Executive Secretary, NHIS, made an argument that Nigeria’s health care delivery system will be better off without HMOs. Photo Credit: Nigeria Health Watch

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.

Leke Ewenla of HMCAN answers questions during the investigative public hearing. Photo Credit: Nigeria Health Watch

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.

A lighter moment as the audience shares a laugh during the investigative public hearing. Photo Credit: Nigeria Health Watch

The Enrollee

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.”

The NLC’s Comrade Ayuba spoke of the plight of the enrollees during the investigative public hearing. Photo Credit: Nigeria Health Watch

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.”

Hon. Chukwukere Ikechukwu (left) said the House Committee will work to investigate all allegations and come up with recommendations. Photo Credit: Nigeria Health Watch

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.”

Discussion4 Comments

  1. I will want to speak as a Patient Safety Consultant on this issue.

    I would rather think it should not be just the NHIS or HMOs that should be blamed on this issue. The entire Nigerian health system is totally sick, we have a total break down in our system where the hospitals have total for patient emotions and dignity. Before pointing fingers at NHIS or HMOs who do not own the hospitals where the patients are treated, I would rather want the Ministry of Health to first look into the standard of these hospitals and the quality of care which is currently lacking. Medical errors, adverse effect, patient harm and even preventable death in the line of care characterize these hospitals that are Nevers regulated. That is where the restructure should begin from, the concept of CANDOR talks about total refund of funds paid and unreserved apologies offered to patients who get harmed or suffer from adverce event in the hospital but that does not happen here.
    The world has moved out of the concept of Physician Centred Care to Patient Centred Care bit in Nigeria, the reverse is still the case. Patients can never get quality treatment in hospitals that are not regulated. When patients get harmed or suffer from medical errors where do they report? Who should they talk to. You can google the case of “Justice for Shawn” which is still very fresh in our memory in Nigeria, I have followed up on that case and I know how the Mother of the deceased has font to both MDCN and NMA but no one is doing any thing. It IAS sad, until we fix this, forget sanity in healthcare.

    The NHIS are the regulators of the HMOs, they should also explain what they have done with these HMOs. Yes, I believe the fact that there is a cartel amongst the HMOs but I see that also as a weakness from the NHIS. NHIS was set up with people that had no clue of what to do in Health Insurance, you need a sound Actuerial Scientist who can analyse and manage risks to run NHIS, we do not necessarily need a Doctor to do that job, not even a Professor. I like what the new Secretary General of NHIS is doing now because no one has ever challenged cartel within this space, they have all connived in time past either to eat and waste publics funds without measurable health outcomes. The quality and hospital.accreditation department of NHIS are the ones vested with the responsibilities of hospital standards and quality before they are signed in to the scheme. Ask the NHIS how many hospitals they have visited for the past 12 years and how many sanctions and delisting have they effected. Even the people NHIS sends out to inspect and accredit hospitals do not know the quality of a safe hospital or safe care, it is sad. These are sets of people who are not trained but they are made to inspect hospitals and hospitals that have no business being in the scheme are all signed in. This is accident waiting to happen, people seeking care have died in quantum through this errors.

    NHIS complains of fund collected and not used, that’s a self indictment on NHIS because it is their responsibility to follow up on how these funds have been disbursed. There are a number of HMOs without registration or licence, they are insuring people, where in NHIS on this?

    I was with a South African friend in Ikoyi last week friday, he is an international Health policy manager and he told me what we have as health system in Nigeria is such a pity, this I quite understand. He told me he went to the hospital in Nigeria and saw a huge apathy of care and segregation amongst patients, strong level of inequality. Someone is so sick, he is insured by a certain HMO, he is made to wait for longer hours to get approval for treatment, it is sad. HMOs take money upfront from.organisations band refuse to pay the hospitals and even.ifnthey pay, it is pittance. e risk they should have been managing on behalf of the insured, is shifted back to the insured. The enrollee now becomes the risk bearer. I have worked across the healthcare sector both in managing hospitals and managing HMOs and I tell you, there has never been sincerity, the enrollees always suffer.

    How can you be so heartless as a HMO, take money on behalf of a certain health population, refuse to pay the hospitals and fix the money while the enrollees suffer delay in hospitals and even some times not even.attended to. Most of the HMOs owners collect money and buy new cars, it is sad.

    First reform the entire healthcare sector, fund better the governemt owned hospitals, let them run commercially with quality of care. Create guildelines and framework for hospitals. Once all these are done, you can not move to NHIS and HMOs for restructuring. Review what currently runs, what are the challenges and gaps, then look at hownto fix it and get it actively regulated.

    These are my views!

  2. The HMO is a welcome development in Health care Service delivery as I am really enjoying mine. I do not know of other Hospitals but I must commend International Hospital Kano for their services that save my life last year when my appendix rapture.
    I never knew HMO was that effective until then when i fell sick.

  3. The hearing is interesting but perhaps it is asking the wrong questions. Questions should be asked about:
    1. Why is the NHIS scheme only covering less than 5% of the Nigerian population?
    2. Why are the state and local governments not participating in the scheme?
    3. Why is regulation weak and without focus?
    4. Why are most private Hospital’s accredited by the scheme unwilling to carry out secondary care?
    5. The NHIS guidelines has a number of grey areas-why does it take so long to review?
    6. Which HMOs owe providers and why did the NHIS not sanction them?
    7. Despite multiple accreditations for providers by various regulators and agencies, why is there a paucity of Quality control and monitoring?
    The entire managed care industry is growing but obviously regulation needs to grow. This hearing appears to already have an agenda before the discussions. The head of a regulator should not be making allegations but taking decisive actions – the actions of the Executive Secretary since assumption of duty has been strong and decisive. A note of caution though, throwing the baby out with the bath water is an easy solution; it comes with its own pitfalls,
    a. An entire industry and jobs would be destroyed and put at risk.
    b. The alternative is not fraud or corruption proof. Government agencies are not known as bastions of integrity.
    c. The NHIS’ reach across the country is not that strong despite their presence in every state capital.
    We must remember Healthcare Financing is a business decision intertwined with a healthcare need, emotions and knee jerk reactions don’t produce the best outcomes.
    From someone who has worn the caps of HMO, Provider, Enrolee and has interfaced with NHIS.

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