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NHIS – Long Road to Universal Coverage

  • Rights of the Patient and Healthcare Provider

The National Health Insurance Scheme has remained as just an idea since 1962 when it was first mooted. The lofty idea as it is, did not come to fruition until an enabling law was promulgated in 1999, and then in May 2005 the programme kicked off in earnest. And down the line the general consensus has been that the scheme that was given legal teeth 17 years ago is yet to seriously get up and run. Editor, MORGAN NWANGUMA in this write-up looks at the programme’s long road to universal coverage, vis-a-vis the rights of the parties involved.

Since the National Health Insurance Scheme project was set in place health watchers and experts alike have come to the opinion and conclusion that so far it has remained largely a paper tiger. According to the Agency driving the scheme, the vision is to secure universal coverage and access to adequate and affordable health care, in order to improve the health status of Nigerians especially for those participating in the various programmes/products of the Scheme.

The Scheme which was established under Act 35 of 1999 by the Federal Government of Nigeria is supposed to be available to all Nigerians through various workable prepayment systems. But to what extent has this dream been accomplished? This is the question critics of the programme are asking. Amongst many other reasons and aims of setting up the bill for the amendment of the act of the health insurance scheme includes – the proper monitoring of Health Care Providers as well as Health Maintenance Organisations (HMOs) that are involved in health insurance for the purpose of delivering effective services, etc.

Performance of the scheme

Pharm. Albert Kelong Alkali, is the Chairman of the Association of Community Pharmacists of Nigeria; he argues that the scheme is not really working, saying that is why very few people are captured in the programme. He posits that if it were really working so many people will love to be captured in the scheme; he stressed that in fact it is the beneficiaries that would have been promoting it themselves, having tasted the goodness of it.

Alkali emphasises that although the whole idea is a laudable one because it is designed to enable one access medical treatment whether you have money or not, if only the programme will be made to function well. As a result of the inefficiency of the scheme he says – is the “reason why many people are not keen on joining.”

Also observing from another angle, Dr. Lawumi Adekola – a medical practitioner thinks that the programme for now merely covers an insignificant population of the Nigerian masses. But he insists that the National Health Insurance Scheme (NHIS) the way it is designed, is a social security arrangement with a comprehensive benefit package. He feels that however, the existing challenges to the scheme can be tackled by making it mandatory and improving regulation and exploring alternative funding.

Looking at it from the backdrop of the scheme which is set out to facilitate fair financing of health care costs through pooling and judicious utilisation of financial resources to provide financial risk protection and cost burden-sharing for people, the telltales are there for everyone to see – that the performance of the scheme so far has been dismal owing to the fact that the (NHIS) act 35 of 1999, until it was amended in 2004, only grew marginally in coverage from less than 150,000 lives in 2004 to about a meager 5 million in 2014, representing just 3% of the population. It also has a denting snag in the fact that for now, the NHIS covers mainly federal public sector workers and their families.

The programme which also aims at mitigating the high cost of health care, through various prepayment programmes/products prior to their falling ill is yet to impact on the lives of the average Nigerian. Another key statutory function of the NHIS demands that it fully provides the much needed regulatory oversight to Health Maintenance Organisations (HMOs) and participating Health Care Providers (HCPs). But most Nigerians as it is are yet to feel its impact in this light.

Observers say that since the programme is set up to ensure that every Nigerian has access to basic healthcare, it then follows that it should be able to protect families while alleviating the cost of maintaining an ongoing financial demand on quality health services, etc. But so far popular opinion is that this dream has remained a mirage.

Challenges before the scheme

Thus the act setting up the programmes clearly stipulates the guidelines while envisaging the likely loopholes and has therefore created penalties for defaulters of the scheme. This programme therefore requires the full cooperation and patriotic zeal needed to adequately ensure universal health coverage. For this reason the Council is enabled to withdraw accreditation issued to any Health Care Provider if it is discovered that false declaration is made in the course of Filing application by the Provider.

There may also be stumbling blocks faced if for instance, the provider is facing any form of insolvency proceedings or is likely to be wound up or dissolved. This will also happen if the provider is in any way not able to further render services to the enrolee, or is not able to meet up with or is seen to be in breach of the required provisions stipulated in the guidelines, of the NHIS, etc.

But from the look of things it is obvious that most Nigerians are yet to even know about the existence of a national health (insurance) scheme let alone embrace it for coverage. At the same time so many factors have continued to be a cog in the wheel of progress of this beautiful idea.

Not many Nigerians are covered in the process and as a result some of the basic aims of the scheme remain defeated because when very few are covered, the nation or the project is not able to garner all the needed resources it requires to run an effective national healthcare delivery. The current picture clearly shows that the government will be lacking in the availability of funds needed to run the health sector for improved services and also infrastructural development.

Legalities:

download (1)According to keen watchers of the scheme and its implementation, lack of adequate funding has remained a serious setback. Also, protecting the right of the enrolee (patient) is very important likewise the right of the caregiver which is vital to having a workable health insurance programme. The government and operators of the scheme therefore need to pay urgent attention to this or else the whole idea would be defeated because so many are in the habit of wanting to cut corners at the expense of others.

Thus the rights of both parties in the scheme especially of the patient remain very critical in the process – knowing the peculiarities of our clime in that they are always at the receiving end of the equation. But it is pertinent to note here that under the NHIS act, provisions have also been made by which the enrolee is protected, and ditto for the healthcare provider.

Rights of the Enrolee

The Patient possesses the right of access to medical treatment; they also have the right to choose a provider of their choice as long as such a provider is accredited by the Scheme. As an enrollee you have the right to be issued with an NHIS identity card after being registered with the Scheme as well as the right to change Primary Healthcare Provider after three (3) months of initial access or, immediately change your provider if the facility is closed, relocated or the employee is on transfer to another town.

The enrollee also reserves the right to complain to the HMO about any act of negligence on the part of the Healthcare providers, and to access medical care for spouse and four (4) biological children. They are also protected by the law establishing the scheme to give constructive criticism of the operational methods of the Scheme, or be referred for specialised investigations or care wherein ‘referral’ means sending a patient for a range of specialised investigations or care through the recognised three levels of services as enunciated in the law.

Buttressing on this point – being that the enrolee has paid for all the necessary services, they ought to benefit from the full professional services of the entire team of healthcare personnel. In the words of Pharm. Alkali, “in a setting whereby a patient is being treated and they are not fully attended to by the requisite professionals, the patient stands to be short-changed in that they have already paid for the services and as such should be adequately attended to.” He says that if for instance in a ‘standard’ clinic or hospital, if a patient is to be seen, a complete team comprising of all the necessary health professionals in addition to the physician, such as a pharmacist, nurses, laboratory science expert, etc, must be in attendance or else the enrolee is already short-changed.

Observers argue that a Laboratory Scientist should be able to take care of your laboratory investigations while a nurse should be equally available to administer the required care and sundry services. With all these put together the medical practitioner in charge is properly enabled to carry out comprehensive diagnosis and therefore deliver adequate treatment to the patient.

Rights of the Healthcare Provider

Healthcare providers under the scheme will be paid by capitation – payment to a primary healthcare provider by the HMOs on behalf of the contributor for services rendered by the provider. It is made regularly in advance for services to be rendered irrespective of whether enrolees utilise the service or not. He is also entitled to payment for services delivered on referral from other approved providers, as well as daily fees for drugs and treatments, etc for each day of hospitalisation of patient.

The provider is entitled to pay for each and every case handled to the very end. And just as with every enrolee, the healthcare giver has right of complaint as may be brought before the Health Insurance Arbitration board in each state of the Federation and the Federal Capital Territory.

In the programme a big role is expected of the formal sector; they are to facilitate the insurance health system by galvanising a social health security system in which the health care of their employees is paid for from funds created by pooling the contributions of employees and employers. This all important segment of society includes – the Public sector, the Organised Private Sector, and then the Armed Forces, Police and other Uniformed Services.

But as it is, the journey remains a long way off with the government having previously set for itself a tall order of achieving universal coverage by 2015. But due to lack of political will, and indeed administrative foot-dragging, the scheme has not been able to achieve much in terms of tangible gains order than the mere existence of the programme.

Thus the programme’s motto of ‘easy access to healthcare for all’ remains just a dream, yet it can be realised when we properly put our acts together. A lot of further public enlightenment programmes have to be put in place while a whole lot of Nigerians need to be empowered for wealth creation. This can be encouraged by way of adequately rewarding employment benefits, and or entrepreneurship development through the creation of enabling environment that boosts the flowering of individual self realization, capacity building as well as job creation.

 

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