National Health Insurance Scheme, NHIS,
•Health care financing in our country is nothing but fraud – Usman, suspended NHIS boss
By Levinus Nwabughiogu
The lingering face-off between the National Health Insurance Scheme, NHIS, and the Health Management Organizations, HMOs, over performance took a disturbing dimension at the two-day public hearing on the activities of both bodies by a Committee of the House of Representatives. The report as captured for Sunday Vanguard.
Until the report is finally put together and made public, apprehension would remain their lot. At the moment, they are unsure of where the pendulum would swing eventually.
They may have made very strong presentations to defend themselves and ward off what, in their own estimation, constituted “blackmail” and lies but it does appear that there is still no conviction within.
Their attempts to stay clean and maintain tenacity were rather seen by many as a futile struggle because, in the court of public opinion, there are weighty allegations against them.
In fact, at the last count, petitions, which accused them of rending poor service, had reached its apogee. Official sources say they were 450 petitions.
Who are these bodies? They are the Health Management (Maintenance) Organizations, HMOs. Their number at the moment is 59. They are mainly resident in Lagos and Abuja. Only their shadows are arguably seen outside the major cities.
For emphasis sake, the HMOs are the go-between in the Nigeria’s Health Insurance Scheme (NHIS). They sit between the beneficiaries of NHIS and the service providers (hospitals). By this description, they are better known as managers of the scheme’s funds.
The HMOs were established in 2005 and had operated freely for 12 years without any form of probe.
But calls for investigation into their activities by those who are mainly the beneficiaries, otherwise called enrollees, reached a crescendo recently, thereby prompting an action at the floor of the House of Representatives.
Since inception, the HMOs have been paid N351 billion. Also, administrative fee paid to them for the period of 12 years is N60 billion and yet they have only given 1.5 percent health in a country of about 180 million people.
Meanwhile, they have a debt profile of N2.276 billion with the hospitals across the country despite the mind-blowing financial releases by NHIS.
Successive governments apparently tolerated them. But the coming of Yusuf Usman, a professor of paediatrics and formerly at St. Jude Research Hospital, Memphis, Tennessee, United States of America, July, last year, as the Executive Secretary of the NHIS, has been nightmarish.
So, on the account of a motion debated at the Green Chamber in December 2016, a public hearing was scheduled by the House Committee on Health Care Services.
Held recently, the exercise was tagged investigative hearing into the “Compliance rate of the Health Management Organizations (HMOs), to the NHIS contributions and Utilization of Funds by the Health Care Providers and Inhumane Treatment of Enrollees”.
Day One of the public hearing
As early as 10am on the first day of the hearing, the Chairman of the Committee, Hon. Chike John Okafor, and his members, numbering over 20, were already seated not minding that the National Assembly was officially on a three-week vacation.
Room 082 of the New Building of the House of Representatives, venue of the hearing, was also filled to the brim as it witnessed unprecedented crowd whose interest in the event was obvious.
The roll call include representatives from the Nigeria Labour Congress, NLC, and the Trade Union Congress, TUC. The HMOs and their leadership were present. The Executive Secretary of the NHIS, now suspended, Usman, led a retinue of his staff to the place. Health care deliverers, ranging from medical doctors to pharmacists, laboratory scientists and technologists, representing various health society and hospitals, were also present. Niger State Commissioner for Health, Mustapha Jubril, came in the name of Health Commissioners across the 36 states of the Federation. In solidarity, the Senate also sent Senator Moa Ohuabunwa, the Chairman, Senate Committee on Primary Health and Communicable Diseases, to represent it. Of course, a critical mass of the enrollees also graced the event.
To all the stakeholders in the room, the, which prompted the hearing, was the of fraud in the health system and that suspicion pervaded the room as the adumbrations came underway.
As if it was a time-bomb waiting to explode, the Minister of Health, Professor Isaac Adewole, represented by the Director of Hospital Services in the Ministry of Health, Mr. L H Balami, at the hearing, lambasted the HMOs for doing little or nothing with the N351 billion received so far.
He hailed the House Committee for the investigative hearing meant to evaluate the activities of the HMOs in Nigeria.
According to him, the exercise would afford members of the Committee and, indeed, Nigerians the opportunity to assess the performance of the HMOs with a view to determining their continued existence.
He said: “While over N351 billion premium has been received from the NHIS by the HMOs, only four percent of Nigerians have been covered so far.
“The scheme needs to perform better if it must justify the huge sums expended by government”, he said, adding that “the role of expanding the coverage of enrollees is that of the NHIS and not HMOs.
“There have been complaints by previous and present NHIS leadership of attempts to undermine their authority by representatives of HMOs who are on the board of the agency.
“Such a situation breeds conflict of interest. The presence of HMO representatives on the board tends to challenge the powers of the NHIS to regulate and sanction erring organisations”.
Adewole’s remarks were nothing compared to what was in the offing as stakeholders were called to make their respective submissions.
The turn of then Executive Secretary of the NHIS, Usman, was explosive. The room was literally set ablaze with hot verbal exchanges. It was a no-holds-barred. Emotions ran high.
Speaking true to power, Usman expressed happiness that a day of reckoning for the HMOs had eventually come. His physical expressions, gesticulations, tone suggested a disgust that “for 12 years, the HMOs have never been called to account for their (deeds) and misdeeds”.
Like the Minister, the NHIS boss also questioned the relevance of the HMOs in the dispensation of health services to Nigerians.
He revealed that upon assumption of office some months back, he had initiated a number of reforms which pinned him against the operators of HMOs; however vowing to inject sanity into the system and take suspected culprits to the anti-graft agencies no matter whose ox was gored.
He said: “More than 70 new born babies and over a 100 women die daily from avoidable mortality, even though they are on the scheme.
“Millions die across the states and there seemed not to be time to fight these anomalies until now.
“When I came to the agency, I saw the potential and I felt the NHIS should perform its duties of helping vulnerable Nigerians to access quality health care.
“The number of Nigerians covered by the NHIS after 12 years is 1.5 percent of the population. Countries like Kenya and Rwanda have achieved better health care delivery without HMOs and health care financing in Nigeria is nothing but a huge fraud.
“I know all these things because I sign the cheques and nobody has been brought to book in the last 12 years. If you want to hear the truth, hear it from me today, because my way of making the scheme work is to hold the HMOs accountable.
“We are told that they are powerful and untouchable because they are owned by some powerful Nigerians, but I have news for you that I’m here to rock the boat. We must sink this boat of corruption that has killed the health care sector of our country.
“They have never been brought to account for the 12 years. The number covered 1.5 percent of Nigerians. You can quote me anywhere because I sign the cheques.
“Health care financing in Nigeria is nothing but fraud. This is the truth. You want to hear the truth, hear it from me. Nobody has done this over the last 12 years.
“In 12 years, we covered only 1.5 percent of Nigerians. They have been padding with complicity. They have formed themselves into a cartel.
“You will be Mr. Magu’s guest. My NHIS will be fighting NHIS. This NHIS will fight for the enrollees.
“Honourable members, these people are your constituents, and these guys operating the HMOs are owing them huge money. The NHIS is supposed to enhance the standard of health care delivery and crash the cost of health care in Nigeria, but covering just 1.5 percent of Nigerians in 12 years, have we achieved the objective?
“Now, I went round and demanded that HMOs pay back the money collected without service delivered, or I delist them, and, as I speak to you right now, over 95% of the debt has been recouped by the NHIS, and as we speak, there are no HMOs in Nigeria.
“And we are going to re- accredit all the HMOs in July and, when you apply to manage a hospital, I must get a letter of non- indebtedness from the Chief Medical Director of that hospital before you are hired.
“We gave them N37billion just for administrative fees, patients go to the hospitals and are treated like lepers because the HMOs have not paid the providers. I had to stop it, and they took me to court, EFCC and ICPC, saying that I must be made to reverse to status quo. What should be the status quo, when you hold on to administrative fees and capitation”?
While declaring the event open earlier, the House Speaker, Yakubu Dogara, who was represented by the Deputy Minority Leader, Chukwuka Wilfred Onyema had said that the exercise was necessitated by the concerns of Nigerians who bemoaned the poor health services under the insurance scheme.
Similarly, the Chairman of the Committee, Hon. Chike John Okafor, said that it was part of the oversight functions of the committee to investigate the goings-on in the health sector.
Giving his remarks, the Chairman, Senate Committee on Primary Health and Communicable Diseases, Ohuabunwa, declared his committee support for the House Committee.
“I am here today to support you on this all-important (assignment). I want to state that I was part and parcel of this act. We were thinking that by 2015, we would have realized…there is a disconnect between the health providers and the implementers. Anything to ensure that the internment of this act is realized, you have the support of the Senate. We need this investigate hearing”, the senator said.
In their harmonized representation to the Committee, the HMOs said that it was unfortunate that the Executive Secretary of NHIS had shown open hatred for them.
All the actions of the Executive Secretary, since July, 2016, pointed to a clear case of open hatred for the operators of Health Maintenance Organisations, direct victimization, deliberate attempt to stifle, disrupt and destroy the health insurance scheme and poor knowledge of the workings of health insurance”, they said.
Making a verbal response to the allegations against them, a representative of a faction of the HMOs, Mr. Lekan Ewenla, regretted that they were washing their dirty linens in the public.
“It is quite unfortunate that the ES has not met with the HMOs. If there are issues, you need to call the HMOs and rectify the issues. If there are issues, it is something we need to discuss and not like this. I wish the House will create another platform for us to interact. We don’t need this public hearing. We are no longer interested in the board”, he said.
Day Two: More stunning revelations
Many would have thought that the seemingly frayed nerves, which characterized the first day of the hearing, would have simmered before the second day, but that was a wishful thinking. There were more verbal vituperations and vilifications.
In fact, provoked by further submissions by the HMOs, Usman, when it was his turn to speak, spilled more beans, revealing their current debt profile to hospitals, tagging them “blood-sucking maggots”.
He also debunked the claims that the HMOs were in touch with the people in their respective domains.
He said: “When I came, I started asking questions no one asked. When I speak, I speak with data. It is not heresy. The issues are not now. We are holding the hearing because I am stepping on toes. I know what I gave the HMOs, each hospital, each place. I have the facts. HMOs are nothing but blood-sucking maggots.
“N60 billion is what we have paid them since 2005. These are peoples’ money. They are not everywhere because my men and women are in the field. They are not there. You come down from your hilltop and cash your cheque and you say you are everywhere. Everybody should serve where they are.
“HMOs, I am going to re-accredit you based on your performance and you are going to pay all.
“N2.276 billion is being owed hospital by HMOs. For you to continue, you have to pay all the debts.
“For 12 years, 450,000 Nigerians only. We have identified corruption. Straight from our office, we will pay hospitals and save Nigerians.
“NHIS should not be allowed to die in the hands of HMOs”.
As an alternative, the NHIS boss said he would enroll over 2.5million Nigerians into to the scheme if he is allowed to deal directly with service providers.
He revealed that he had reduced the three months payment (upfront) to the HMOs to one month in order to gauge their performance and stem the rising tide of fraud.
Earlier in the day, the Deputy Chairman of the committee, Muhammad Usman, stated the positions of the NLC and TUC, saying that they would prefer direct transaction with hospitals.
The TUC had called for the forensic audit of the HMOs to ascertain the true situation of issues.
“How can we cover the 180 million Nigerians using the NHIS? We are here for Nigerians and we want the NHIS to work”, he said.
The Committee Chairman, Okafor, remarked: “There are critical questions we’ve posed as part of what stared us in the face yesterday, which is that, how do we satisfy the needs of the enrollees, and that must we have a third party player (HMOs)? Will there be any problem if hospitals are paid directly”?
He, however, said that the committee would expose the erring HMOs, assuring that those living up to expectations would not be unduly punished.
“We will expose the HMOs that have cause these tears. We will make sure that no HMO that has been sweating and paying the health providers will be unduly punished”, he said.
He however reminded the Executive Secretary that serious punitive measures would be meted out to him if it is eventually found out that he ran foul of the law by reducing the payment timeline from three months to one month.
In his remarks, Dr. Mustapha Jibril, who represented Commissioners of Health in the 36 states, underscored the need to domesticate the scheme across the country.
“Currently, the role of the states is not captured in the NHIS law and we are supposed to be in the scheme to domesticate NHIS by way of amendment to the current Act to capture the role of the states.
“After listening to the HMOs yesterday, I want to say that they were not able to defend their position with regards to the allegations of capitation and administration fees which I think is a very large amount.
“We would like to see the HMOs given a different role to play in this, while they are also decentralised, since most of them are currently based in Lagos and Abuja with other states largely devoid of HMOs.
“It’s unfortunate to note that 12 years after, the scheme has been able to enroll just 1.5% of our total population.
“In countries where the health insurance scheme has been successful, the services of the HMOs have been eliminated. It has been practised in Ghana, Kenya, Rwanda and other places.
“Ghana set out on their health insurance journey five years ago, and record has it that they have achieved over 80 percent coverage for their population”.
Also speaking on behalf of the Association of Health Care Services Providers, Dr. Ugwu Ukachukwu Odoh called for proper implementation of the laws regulating the scheme for effective service delivery.
“In principles, concept and design, the Federal Government of this country put together a formidable NHIS for Nigerians to rescue us from poverty, health degradation, but at the end of the day, what do we have, we have a beautiful concept on paper but in reality, the reverse has been the case.
“Any provider operating in less than any of these critical threshold is running at a loss. Over 95 percent of providers are simply subsidizing the health care of ordinary Nigerians. Because we are uncommon businessmen due to our training to save lives.
“Today it is said that N351billion has been spent in the last 12 years, but I can tell you that trillions have exchanged hands under the table.
“HMOs have been allowed to become too powerful in the scheme playing the roles of both middlemen and service providers”, he said.
But Dr. Tunde Ladele, who chairs a faction of the Association of HMOs, wouldn’t stomach all the darts thrown at them.
He blamed NHIS for misrepresenting the facts before the committee and Nigerians, adding that “70% of whatever amount quoted as being spent on the scheme goes to the service providers”.
The leader of the other faction of the HMOs, Ewenla, who is also the Publicity Secretary of the Association of Health Managers, accused the NHIS boss of high-handedness.
He said: “The current Executive Secretary of the NHIS went as far as appointing a single insurance broker for the HMOs as opposed to the list of multiple brokers on their website from where HMOs choose brokers in the past based on preference.
“He also went further to negotiate insurance premium on behalf of HMOs higher than what obtained without our inputs”.
Meanwhile, a mild drama ensued in the course of the proceedings when the Committee Chairman randomly called an enrollee who later gave his name as Olalekan Oluleti, a pharmacist, to bare his mind on the performance of the scheme.
Narrating a story of how he assisted a pregnant woman at a private hospital through the HMOs service in Abuja to obtain medicare during a national strike of resident doctors in public hospitals, the enrollee called for caution in the demands to scrap the HMOs.
Mentioning a particular HMO, he said that had there not been such service in place, the woman’s life would have been in more danger.
“Who are we replacing them with?
The HMOs are doing their best. If there are no HMOs, what would have happened when public hospitals went on strike. We should sit down and look at every side of it rather than calling somebody a bad name maybe because we don’t like their faces”, he warned.
His testimony sparked commotion in the audience amongst whom were many who disagreed with him.
The shouts of “shut up and get down. You are not speaking the truth! Where do you work. Lies! What you are saying are lies”, rent the air.
Swiftly, many participants raised their hands in protest, apparently ready to counter the claims.
For over five minutes, the room turned rowdy.
To calm the crowd down, the Chairman of the Committee said Oluleti was randomly picked.
“I don’t know the man. When I called for hands, it was his hand that went up first. I have some names here but I decided not to call them”, Okafor said.
He later gave opportunity for more contributions.
This saw the coming of Hajiya Fatimah Abdulkadir, another enrollee and midwife, who shared her own experience in a private hospital when her son was rushed there.
According to her, the authorities of the hospital after the diagnosis and prescription of drugs for her son told her to pay for the services.
When she referred to an HMO as her cover, the hospital advised her to buy the drugs from a regular shop.
She lamented the rot in the system, saying that she ended up treating her child.
This also caused another round of commotion.
But another enrollee took a middle course, saying that a holistic approach needed to be taken to overhaul the system.
“I want to ventilate my problem with the whole scheme. The pricing since 2005 has been very, very ridiculous. Whether it is NHIS or HMOs, we cannot recycle the money meant for drugs. Let’s have a holistic approach to this and overhaul the act”, he said.